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HomeMy WebLinkAbout0336 OLD MILL ROAD - Health 336 Old Mill Road Osterville A= 142-062-002 Commonwealth of Massachusetts �a- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'�• 336 Old Mill Road Property Address Elizabeth McNamara co Owner Owner's Name information is required for every Osterville ✓ MA 02655 7/11/2016 page. City/Town State Zip Code Date of Inspection tv .i+ Inspection results must be,submitted on this form. Inspection forms may not be altered iin any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford key the return Name of Inspector Y Ford Septic Services, LLC tab Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth valuation by the Local Approving Authority 7/13/16 Inspe s Signa re Date - The s em 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 runder 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. (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0 V Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. Cityr own 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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. r *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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments ssments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments sments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 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: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified.laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No . ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 '/ day flow 15ins+3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments �M a 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of apriva te water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Volunta ry Assessments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. Citylrown C. Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ❑ N 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 avaihable note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(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 n/a (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments �'��a,••y'F 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA - 02655 7/11/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zi Code P Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped yearly Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 z Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'�t 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed - unknown -orginal system Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Septic Tank (locate on site plan): Depth below grade`. cover to grade feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ® other(explain) Cesspool acting as a septic tank. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M A,• 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The cesspool!was 4'W x 57 x 7'BTG, The tees were present The liquid was up to the outlet pipe Grease Trap(locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zip Code Date of inspection- D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: . Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: - ❑ .Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System Form - Not for ry Form Voluntary Assessments • e 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zi Code P Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. Cityrrown State Zi Code P Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The overflow cesspool was 4'W x 57 x TBTG, The cesspool had 2'of water on the bottom Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration n/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts • H _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments essments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a e 1 l 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Old Mill Road Property Address Elizabeth McNamara Owner information is Owner's Name required for every Osterville MA 02655 .7/11/2016 page. City,Town State Zip Code Date of Inspection D. System information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �- - Q GAr4%L 33 31 Ar a s3 y 9 a l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 30'+/- 1 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: Topo and water contours map. ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • •t Commonwealth of Massachusetts • H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments essments `,M a °• 336 Old Mill Road Property Address Elizabeth McNamara Owner Owner's Name information is required for every Osterville MA 02655 7/11/2016 page. City/Town State ZipCode Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �o0r r 1 r�� OLIJ 6 erj Fr IMI i \ f 9� iT zoo pro Q .. l M � a � E - ` IIOi61n rrJ:.7^lrtrf • r; _y 11 A• ij :YkIPq tl7Mbl1� �HII.ILE'� 1 '��.� 15'D FE•L.'1' I'P.PE•iC � PL`(wo:D e KAFTcRS r oc I I��tIJSVLF+'I'IDIJ I r 3 YrRAPPIhI:; f1` i CT PL.Ywa'v zM0 p-.R, J.DlST6D'ISVOC U-APB/?OJ2DS � I w'�ST2APFIhIGti' I/Z";sYPgVM g�ARD: ' 6Jit.olticr PP.GER Pt.YV/OOP I y/q° f ;r PLYWoov 3%z"I1JsuI.,�rlorJ -- ZxIO FL +.e-r Bo. Ek.FaG� k.lO15t55:1/o°oc Zi-4�'7TL.)pS k1• I�"�oc 1 SIC %YF:'-sUM ED. rally SPsh! rF 9� _ ............ \ 1 iY I on o r { rj r , I � T 4 g No. c9 / 8,7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9ppliLatlon for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade VAbandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 33 6 O t» M%%( r z Owner's Name,Address,and Tel.No. PO (�y 5b lk �J� Assessor's Map/Parcel u- L4urevi � (Vl�•�� dl ilk Installle�r'.s�N-am,Address,4nd Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms t2 Lot Size q,5 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Sy 14em i S 9v S o n 3� �,44jyl W, 1,1 ID v �a e!f-� Z-0 trL Date last inspected: 1 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 is Board f Health. Signe Date V Application Approved by Date (� Application Disapproved by Date for the following reasons Permit No. Date Issued n �,1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(°') Upgraded � ( ) Abandoned( )by �GC� C� �� 1�Vk_ ` at O Cl�t` (� �V V'� l ..has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer S Designer #bedrooms Approved design flow gpd The issuance of this permit shall pot be co trued as a guarantee that the system a 'geed. Date ;/1 o 2 ✓ Inspect A r No. O� / Fee /Vv •• 9 computer: ,;,,,.,�,�• THE COMMONWEALTH OF MASSACHUSETTS Entered in com p ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for ;Disposat6pstem Construction Permit _ Application for a Permit to Construct( ) Repair( ) Upgrade,'VAbandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 33(o O t IO rn,11 (2Z ' Owner's Name,Address,and Tel.No. QO B X(l y� LR vreh Mc Na.Ma•r / Assessor's Map/Parcel Installer's Name,Address, d Tel.No. r• Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size J 9 v sq.ft. Garbage Grinder( ) d Other Type off Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 11gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title s Size of Septic Tank Type of S.A.S. Description of Soil r, Nature of Repairs or Alterations(Answer when applicable) m ._j S v4 ov Se. 4 S Z Y� S� 1 r1 1 L t -�` c� `�►c9 V V Q e pr' :f�U 0-9 t ce CU rt Si�TVCAL klAnW l 1p v L yD i v� t=a 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 beep issued is Board of Health. / l Signe Date Application Approved by Date t Application Disapproved by Date for the following reasons Permit No. Date Issued _: --------- _ ---- --- -- .- ---- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliattte THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( ) Abandoned( )by S C c�)C� V at ( Cp�k-k-N\`VQ—.has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer SCC, r-` 11.. ,-< Designer #bedrooms Approved design flow gpd The issuance of this permit shall pot �bee collp�trtueed as a guarantee that the system'" i•1.1-fftinction e ' ned. - specto - .- - - - ---------------- - --------- - - ------------------ 1, No. / - 7 Fee THE COMMONWEALTH OF MASSACHUSE'�TS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstetn Construttion Vermit .... �•1 . Permission is hereby granted to Construct( ) Repair(V) Upgrade( ) Abandon System located at O i j n/�t ` (� o 5" Er u\ w a, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m st be c mpleted within three years of the date of is permitt Date (�j �/ �� Approve + 4 r Citizen Web Request Page 1 of 1 r�BARKSTd13LF, t .. Citizen Request Management' - 4y Request ID: 39338 Created: 4/27/2012 9:11:14 AM Status: Assigned To Staff Assigned To: Desmarais, Donald Health Office Anonymous: No Category: Title 5 : Section 353-7 Sewage' E.C. Date: 5/11/2012 Created By: Wadlington, Ellen Citations: Health Office Time Worked: -0 Response Time: 0 Request Location: 336 OLD MILL ROAD Osterville, Ma 02655 Parcel Number: Map: 142'Block: 062 Lot: 002 Request: Called to site on a fire matter. Discovered open cess pool in back yard. House is being remodeled. Covered with old door and put blocks on door. E Request Work History: ;711 http://issgl2/InternalWRS/WRequestPrintPub.aspx?ID=39338 4/27/2012 COMMONWEALTH OF•MASSACHUSETTS ? t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5•' OFFICIAL.INSPECTION FORM- NOT FOR VOLUNTARY.'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_FORM. PART A CERTIFICATION Property Address: 336 Old Mill Road Osterville,MA 02655 Owner's Name: Kerry McNamara CJ). Owner's Address Date of Inspection: November 10. 2011 Name of Inspector: (Please Print) hires M.Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number::'' (508):862-9400 CERTIFICATION STATEMENT ; I certify that I have personally.inspected the sewage disposal system,at this address and that the information reported: below.is.true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I air a.DEP approved system inspector pursuant to Section 15.340 of Title 5(310.CMR 15.000.) The system;. ✓ Passes Conditionally Passes eeds Further Evaluation by the Local Approving Authority'' ails Inspector's Signatures Date November�'l4, 2011 - The system inspector shall s it a copy f this inspection report to.the,Appi'ovrng Authority(Board of Health or DEP)within30 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: . iNotes and Connnents - ****This report,only describes conditions atr the time of inspection and'under the conditions of use'at that time. This inspection does.not address how the system Will perform in the future under the same or different conditions of use. Title 5 Inspection Fohn` 6/15/2000 ;t page l ` Page 2 of 11" OFFICIAL INSPECTION FORM NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION. (continued) Property Address: 336 Old Mill Road. Oster-Wle•MA Owner: Kerry McNamara Date of Inspection: Nove»iber 10, 2011 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D .A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15:304 exist. Any failure criteria not evaluated-are indicated below. Comments: B. System Conditionally Passes One or more system components as described iti'.the"Conditional Pass" section need to be replaced or " repaired. The system,upon completion of the replacementor repair,as approved by.the Board of Health;will pass.' Answer yes,no or not determined(Y,N,ND) in the for the following statements.,If"not determined",please . explain. r ;The septic tank is metal and over 20 years`old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or enfiltration or tank failure is imminent: System`will pass inspection if the existing.tank is replaced with a complying septic tank as approved by the Board of Health. - *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance " indicating that the tank is less than 20 years old is available: ND explain: Observation of sewage backup or 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 pipes)are replaced obstruction is removed a.distribution box is leveled or replaced ND explain: The system required pumping*`more'than"4 times a year due to broken.or obstructed pipe(s). The system will pass inspection if(with approval of the`Board.of Health): ' broken pipe(s)are'replaced'�' obstruction-is removed ND explain: .: • r 2 r Page 3 of 11 OFFICIAL INSPECTION'FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 336 Old Mill Road Osterville.MA• Owner: Kerry MCNaMara Date of Inspection: Novernber.10,`2011 C. Further Evaluation is Required by the Board of Health: Conditions_exist which require further'evaluafion by the Board of Health in order to determine if the system is failing to protect public health,safety or the.;environment: ' L System will pass unless Board of Health determines in accordance with310 CMR 15.303 (1)(b) that the. system is not functioning in a manner which will protect public health,safety and-the environment: Cesspool or privy,is within 50'feet'of a surface.water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh r fi 2. System will fail unless the Board.of Health(and Public Water.Supplier,if any) determines that the system is functioning in a manner that protects the public Health;safety and environment: The system has a septic tank and soil absorption system(SAS) and.the SAS is.within 100 feet of a - surface water supply or.tributary to a surface wafer,supply: r .. i. 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'ormore from a.:' private water supply well**. Method used to determine distance **This system passes'if the well water.analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic,compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.,A copy of the analysis must be attached to this,form. 3. Other: >, . 3 t • Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM -PART A CERTIFICATION (continued) Property Address: 336 Old Mill Road Osterville,MA Owner: Kerry McNamara Date.of Inspection: Novemb6-10.2011 D. System Failure Criteria applicable to all systems: . You must indicate either"yes"•or"no"to each of the following for all inspections Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ` cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less tliari%z'day flow ✓ Required pumping more than times in the last,year NOT due to clogged or obstructed pipe(s). Number of times pumped._.' ✓ Anyportion of the SAS,'cesspool or privy is below high ground water elevation ✓ Any portion of cesspool cr privy is within 10.0 feet of a.surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 11 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 0•feet from a private water supply well with no acceptable Water.quality analysis. (This system passes if the well water,analysis, performed at a DE,P certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility,and the presence of ammonia nitrogemand nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.' A copy of the analysis must:be attached to this form.] No (Yes/No)The system fails`. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303;therefore the system fails. The system.owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large System: To be considered:A large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must.indicate either."yes"or."no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) , Yes No _ the system is within 4001feet of a surface drinking water supply _ - the system is'within 200 feet'ofa tributary*to a surface drinking water.supply the.system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-'IWPA)'or a mapped Zone II of a public water supply well If you have answered"yes"to anyquestion 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 contactIttle appropriate regional office of the Department. Page 5 of I 1 ' OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B t CHECKLIST Property Address: 336 Old Mill Road Osterville, MA Owner: Kerry McNanwr-a Date of Inspection: Noveniber`10. Mil ' Check if the following have.been done:S You must indicate"yes"nor"no"as to each 'of the following: Yes No ✓ Pumping information.was provided by the owner,occupant,or Board-of Health ✓ Were any of the.system components'pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? h Have lar e volutn 'es of water been-introduced oduced t th g _ ,, o, e system recently.or as part of thrs'.mspection? ✓ Were as built plans ofjfie system obtained and examined? (If they were not available'iiote asN/f1) ✓ Was the g p g 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 ofscum? _ Was the facility owner(and occupants if different from owner)provided witli information on the proper.' maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No z ✓ Existing information. For example,a plan at the Board of Health ' ✓ Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. . a `J , w _ ... .. f Page 6 of 11 OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 336 Old Mill Road Osterville.MA Owner: Kerry McNamara. Date of Inspection:. November 10, 2011 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 y. , DESIGN flow based on 310 CMR 15.203 (fqr example: 110 gpd x#of of 440 " Number of current residents: 0 . Does residence have a garbage grinder(yes or no):. No ' Is laundry on a.separate sewage system(yes or no):. No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available'(last 2',years usage(gpd)): . Unavailable Sump Pump (yes or no):. No. Last date of occupancy: U known COMMERCIAL/INDUSTRIAL Type of establislunent: Design flow(based on 310 CMR 15 203):. gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):. „ Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): q . Water meter-readings,if available: Last date of occupancy/use: - OTHER(describe): - - s GENERAL INFORMATION' Pumping Records Source of information: Unavailable Was systempumped as part of the inspection',(yes or no): If yes,volume pumped: gallons-=,How was,quantity pumped.determined? . Reason for pumping: TYPE OF SYSTEM. Septic tan k,distribution box soil absorption on system m Single cesspool ✓ Overflow cesspool Privy Shared system(yes or no) (if yes;attach previous inspection records,if any) Innovative/Alternative technology. Attach,a copy of the current operation and maintenance contract(to be. obtained from system owner) Tight Tank Attach a copy of the DEP approval' Other(describe): s Approximate age of all,components,date installed(if known)and source of information: Date of installation unknown;orikinal system Were sewage odors detected when arriving at the site(yes or no): No 6 t Page 7 of I 1 s OFFICIAL INSPECTION.:FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a SYSTEM INFORMATION (continued) Property Address: 336 Old Mill Road' Osterville. MA Owner: Kerry McNamara Date of Inspection: Noveniber 10, 2011 BUILDING SEWER(locate.on site plan) , Depth below grade: Materials of construction: cast iron _40 PVC other(explain):. Distance from private water supply well or suction line`. Comments(on condition of joints;venting,evidence of leakage, etc.): SEPTIC. TANK: ✓ (locate on site plan),' _(Cesspool acting as aseptic tank)-- Depth below grade: Toirade , Material of construction:, concrete metal _fiberglass _polyethylene ...: other(explain). Stone If tank is metal list age: Is.age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 4'W x S'T x T bottom to'Qrade Sludge.depth: Distance from top of sludge to'bottom of outlet'tee or baffle:,, Scum thickness: -- Distance from top of scum to top of outlet*tee or baffle Distance from bottom of scum to bottom of outlet.tee or baffle: -- How were dimensions determined: Meascu`i4g stick. Conunents(on pumping recommendations,mlet'and outlet tee,or baffle condition;structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):,. 6 The cesspool was dry. The outlet tee was present GREASE TRAP: : None (locate on site plan) Depth below grade: Material of construction: .. concrete _metal _fiberglass _``.polyethylene _other.* ' (explain): : . , Dimensions: Scum thickness: Distance from top.of scum to top of outlet tee or baffle: . . Distance from bottom of.scum to bottom of outlet tee,or baffle: A` Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet.invert,.evide.nce'of leakage,etc.):. 7 r Page 8 of 1.1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C +, SYSTEM INFORMATION (continued) Property Address: 336 Old Mill Road Osteiville.M.A Owner: Kerry McNarzai a Date of Inspection: November 10;2011 TIGHT or HOLDING TANK: None tank must be um ed at time of inspection) locate on site lan ( p, p P ) ( p . ) Depth below grade: Material of construction: _concrete _metal _fiberglass -polyethylene "=other(explain): Dimensions: Capacity: g allons . Design Flow: . gallons/dav Alarm.present(yes or no): Alarm level: Alarm in working order(yes or no) Date of last um in` p P g: ,. Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet,invert:' Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc:): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no) Alarms in working order(ye s'orno) Comments(note condition of pump chamber;condition of pumps and appurtenances,etc.): — s I 4 y - 8br Page 9 of a l OFFICIAL:INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _: PART C SYSTEM INFORMATION (continued) Property Address: 336 Old Mill Road Osterville,MA +. Owner: Kerry 1YIcNarnar a Date of Inspection: November 10, 2011 SOIL ABSORPTION SYSTEM(SAS): ✓+ (locate on site plan,excavation not.required) If SAS not located explain why Type leaching pits;number: ' leaching chambers,number: leaching galleries,number: , r leaching trenches,'number,length:'- . leaching fields,number,dimensions: .. . overflow cesspool;number: l Innovative/alternative system Type/name of technology. Comments(note condition of soil,signs of hydraulic failure;level of ponding,damp soil,condition of vegetation;etc.):, The overflow cesspool was 4'W x S'T x 7'bbttoni to grade There did not appear to be'dny signs offailur e The'cover was 2" below Qr ade. CESSPOOLS: (cesspool must be pumped as part of inspection) locate on siteplan) 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.inflovi(yes or no) Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: vj Dimensions Depth of solids:. Comments(note condition of soil;signs of hydraulic failure,level of ponding,condition of vegetation;etc.): a - 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO RM PART C SYSTEM INFORMATION (continued): Property'Address: 336 Old Mill Pioad Osterville,MA: Owner.: Kenn McNamar a` Date.of Inspection:, 'Noventher 10,'201'1.. SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal.system ineluding ties to least two permanerifreference landrriarks or benclunarks. Locate all wells within 100 feet. Locate where public water supply enters the building r t 33 37 " t i 10. . "' ` " Page 11 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) Property Address: 336 Old Mill Road' Osterville,M.4_ Owner: Kerry Mc1Uau ara Date of Inspection: Noventber 10,72011 SITE EXAM Slope Surface water . Check cellar Shallow wells Estimated depth to ground water. 30 +/ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site.(abutting property/observation hole within 150 feet of SAS) ✓ Checked,with local Board of Health-explain: topoQr-aUlzic and.water contours maps Checked with local excavators,installers—(attach.documentation) Accessed USGS database-explain: F You must describe how you established the high groundwater elevation: Using Barnstable topographic and water contours maps, the neaps ivere showing approxirnatelY 30.'+/-to jumind water at this _ site. . . i This report has been prepared:only for.the septic system and components described herein. This septic system yeas. inspected and passed as of the date.of inspection. This report is not a warranty or guarantee that the system will fiuiction properly in the fitture. There'haue been no warranties or gzzarantees, either expressed, written or implied, - relating to the septic system;the inspection, this report and/or any components of the septic system which have not been located and.inspected: 11 c,v, 15, 2011 p: 1Or',M phi). 0220 i. t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 336 Old H61.Road Osrerville,Al.A 02655 Owner's Name: Kerry McNamara Owner's Address: Date of Inspection: Novenrb 10, 2011 Name of Inspector: (;Please.Print) James M.Foul' Company Name: Janes M. cord Mailing Address: P t7.Box 42 OsienNille,NA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that 1 have personally inspected the szwage disposal system at this address and that the information reported below ts.true,accurate and complete as of the time of the inspection. The inspection w35 performed based wi my training and experience in the proper functiotl and maintenance of on site sewage disposal systems. I am a 1)EP approved system iitspectar pursuant to w'ectiott.15.340 of Title 5(310 CMR 15.000). The system: ✓" Passes Ponditionally Passes reds Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: November 14,20I1 The system inspector'shall s t a copy f tris inspection report to the Approving Authority(Board of Health or DEF)witI)ia 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system.owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Con=ents ""**This report only describes conditions at the time of inspectiou aad under the conditions of use'at that time. This inspection does not address how the.system.will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 p<sgc l N,)v, 15. 2011 8: 11AM �i�, 0220 F. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- 336 Old lMU Bead Osterville 14A Owner: lC ry mc11tamara Date of Inspection: November 10, 2011 Lispecti.on Summary: Check A,B,C,D.or E/'ALWAYS complete all of Secti.oit D A. System Passes: I have not found any information which indicates tharany of the failure criteria described in 310 CiAR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments: 13. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic lank is metal azid 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. gA metal septic tank will pass inspec-tion if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high,static water level in the distribution box due to broken or obstructed ppe(s)or due to a broken,settled or uneven distribution box. System will pass inspections if (with approval of Board of Health), broken plpe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _ The system rertuired pumping-more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is.removed ND explain.: N,.,v. 115. 2011 8 1 AM Nc, 0220 P. Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property Address: 336 Old Afid Road Osterville AM Ownei: li'era ma,a Date of Lispection: Noveitaber 10.2c711 C. Further Evaluation is Required"by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health;safety or'the environment. 1. Systein will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fall.unless the Board of Health(and Public Water.Supplier,if any)determines that the, system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption,system(SAS)and the SAS is within 100 feet of a surface water supply or"tributary,to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well", Method used to determine distance X+This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforrn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of anunoma nitrogen and nitrate nitrogerx is equal to or less than 5 rpm,provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form. .3. Other- 3 r Nov. 15. 2011 8: 11AM No. 0,220 P. 4 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTMICAT'ION (continued). Property Address: _ 336 Old Mill load t�stewilla.tl�� Owner: Kerry L"M mara Pate of Inspection.: Nove,nber 10,2011 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the follow-Ing for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'%day flow Required pumping more than 4 tunes in the last year�T_due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary'to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well, ✓ Any portion of a.cesspool or privy is within.50 feet of a private water supply well, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEF certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) r�(Yes/No)The system f I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system,fails. The system owner should Contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To he considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria,apply to large systems in addition to the criteria above) Yes Na 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 IL 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 amwered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under.Section F or failed under Seetioft D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. 4 Nov. i). 2011 8 12AM No. u220 1` � Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 336 Old Mill Road _ osterville.M4 Owner; _ Kerry McNamara Date of Inspection: Noyp-mbeY 10. 2011 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No Pdmping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available,note as NIP,) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected fo;sigus 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 tapk,inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of.slu.dge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on.the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(.SAS)on.the site has been determined based on, Yes No ✓' Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CM 15-302(3)(b)].. 5 Nov. i5/. 2011 8: 12AM No. 0220 K 0 Page 6 of 1 I OFFICIAL INSPECTION(FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 336 Old Afill Road Ostervillc.MA Qvvner: Kerry McNamara Date of Inspection: November 10, 2011 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design); n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: L10 gpd x#of bedrooms): 440 Number of current residents' _-Q_ Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No jif yes separate inspection required] Laundry system inspected(yes or no): N� Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): �Q Last date of occupancy: Unknown COMMERCJAL/INIDUSTRIAL Type of establisluni�nt: _ Design flow(based on 3 i0 CivIR 15.203): _. _Qpd Basis of design flow(seats/persons/sgft,etc.): Grease crap present(yes or no): -- Industrial waste holding tank present(yes or no) Nan-sanitary waste discharged to the Title 5 systern(yes or no); Water meter readings,if available: Last date of occupancy/use: OTHER(describe); _ GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _ Singlc cesspool ✓ Overflow cesspool Priw Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/alternative technology: Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the Dire approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of imtailation unknown-original sysRV7% Were sewage odors detected when arriving at the site(yes or no): N9 6 v 1 F, 2011 8: 12AM No. 0220 ?. 7 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 336 OId,WII Road Ostewifle...iLft1 Owner: Kerr-v.McNamara Date of InspeeOop.: Nayem.12er 10, 2011 BUILDING SEWER(locate on site plan) . Depth below grade: Materials of construction: =cast iron �40 PVC other(explain):_ Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC,' TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: To grade Material of construction: —concrete _metal -fiberglass .'polyethylene other(explain) Stone If tank.is me.-tat list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certif cafe) Dimensions: 4'W x i'T x T bottom to grade Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: , -- Scum thickness: Distance from top of scum to top of outlet tee or baffle: - Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Measuring,£tigk Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �•he cesspool was dry. The outlet tee was present. GREASE TRAP: Nome (locate on site plan) Depth below grade: Materiat 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: Commments(on.pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence ofloakage,etc.) Nov. 15, 2011 3. 12AM �:Vo: II�ZI) r. n I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 336 Old Mill Road Osterville,MA Owner: Keay McNamara Date of Inspection: November 10. 201 j TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete ,metal fiberglass `polyethylene ^other(explain): Dimensions: Capacity: -gallons gallons Design Plow: gallon3/day Alarm present(yes or no): Alarm level: _ Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ne (if present must be opened)(locate oil site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CLAMBER: one (locate on site plan) Pumps in working order(yes or no). Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.); Ndov. 1�. 2r�11 8, 12�,ti" No. 0220 F. 9 Page 9 of I 1 OFFICIAL INSJPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 336 Old Mill,Road Osterville,MA Owner: Kerry McNamara Date of Inspection: November 10.2011 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not Iocated explain.why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions; ✓ overflow cesspool,number; _ Iwovativelalternative system, 'Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,Ievel of ponding,damp soil,condition of vegetation,etc.): The 2ver'flow cesspool was 4'Wx S'T x 7'bottQm to gradg Theme did not appear fo be any suns of failurg The cover was 2" belona ade. CESSPOOLS: `(cesspool must be pumped as part of inspection)(locate on site plan) Nw-nber and configuration: -- _ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no); Conunents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.): PRIVY: one locate n site Ian Ib ( o p _ ) j Materials of construction; Ditnensioris: _ Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.): 9 Nov. 2011 8. 13AhPi No. QD) V. Page 10 of i l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 336 Old Mill Road Osterville,MX Owner: Kerry McNamara Date of Inspection; 1Jovemher 10, 2011 w. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 33 17 10 n20 I. Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 336 Old Mill Road Oster•��ille.Mel . Owner: Kerry McNamara Date of hispection: November 10, 2011 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +j_ feet Please indicate(check) all methods used to determine the high ground water.elevation: Obtained from,,system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: tomgraphic and water contours mans Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain,: You must describe how you established the high ground water elevation: Clsing,Um nstablc(opo2raphic and water contours rnays, the maps were showing approximately 30`+/-to ground water at this site, - This report has been prepared onlyfor the septic system and components de,c,-H&ed herein. This septic system ryas inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will fin,clion properly in the ficture. There have been no avarrarzties orguarantees,either-expressed, written or imphed relating to the septic system,the inspection,this report and/or any components of the septic.systern_rvhich have not been:located and inspected. - it