HomeMy WebLinkAbout0555 OLD MILL ROAD - Health 555 ® MILL ROAD
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Commonwealth of Massachusetts
;n Title 5 Official Inspection Form s ,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4
r
555 Old Mill Road
Property Address p
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019 C:Y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information SI4t-f3it*
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
Cityrrown State Zip Code
ran 508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 6
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
a+
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6/26/2019
Ins ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
wl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City(Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 555 Old Mill Rd Osterville is served by a Title V septic system consisting of a
1500 gallon septic tank, distribution box and.3 500 gallon leach chambers. The system was found to
be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
e</
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019.
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:.
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or;privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form: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
r �r
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,_cesspool or privy is below high ground water elevation.
❑ ® 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 6 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-
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.
6) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
ra Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
tl 555 Old Mill Road
v—
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osteryille Ma 02655 6/26/2019
page. Cityffown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 hpd
Description:
Number of current residents: 4
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
Last date of occupancy: currentDate
l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
+ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. !� 555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
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 I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Original system installed 8/29/2016
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3feet
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 ok, no leaks or blockages. Vented through roof
t5insp.doc•rev.7/26/2018 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
L� 555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 2.5-3.5'feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallons
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2°
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of.scum to bottom of outlet tee or baffle
11"
How were dimensions determined? opened covers and took
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance.. water level was even with outlet, tank was not leaking and was structurally sound.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (Ibcate 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
1n Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
e� 555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
oil
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 level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
I
Commonwealth of Massachusetts
- �p Title 5 Official Inspection Form
th Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osteryille Ma 02655 6/26/2019
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
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:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ Reaching trenches number, length:
❑ Reaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of 3 precast leaching chambers. Leaching facility was video inspected from d-box and
was found dry with no stain lines indicating there has never been standing water.
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-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
i
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,�. 555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osteryille Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate cn 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
1= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osteryille Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
L
Commonwealth of Massachusetts
1: -r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is Osterville Ma 02655 6/26/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
LA
�3 s .2-s
t•
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
1� --- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
tilt
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
555 Old Mill Road
Property Address
Steven Coombs
Owner Owner's Name
information is required for every Osterville Ma 02655 6/26/2019
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 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
tE
TOWN OF BARNSTABLE
LOCATION 0 l� P'fr 1/ SEWAGE# 2�0/6 — t�
VILLAGE ( S�C�-fit ASSESSOR'S MAP&PARCEL f Y!Y o(O-C 03
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /,5_8 in
LEACHING FACILITY.(type) .3 Sao CIOA M size) 3 S�'a[
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) && Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) V Feet
FURNISHED BY
17
V
rAlk,(< A --A/j 13 Av-,- 6
9 3z Z3 qls-
No.
' O FeeO
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
.k YesPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplitltion for Disposal *pstem Construction Permit =
ro
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) omplete System ❑Individual Components
Location Address or Lot o. OG �LG �� Owner's Name,Address,and Tel.No.
o���zrro�c�
Assessor's Map/Parcel 0 -00 j pG,®077/4[ (yA
Installer's Name.Address and Tel.No.,f O $ -f�2,7 �- Desi ' Name, ddress and T 1. o.
Gcl��� ufft ft� 5�r�� �-
6 S Pgy D so- yw y F _d
Type of Building:
Dwelling No.of Bedrooms Lot Size 91 1Z ,) OY�
q.ft. Garbage Grinder(�
Other Type of Building �S/Q �I�,Lr No.of Persons Showers F--- Cafeteria
Other Fixtures /16-
Design Flow(min.required) ® gpd Design flow provided 7 gpd
Plan Date / Number of sheets Revision Date A/1A
Title
Size of Septic Tank / Type of S.A.S. "1� fi
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code not to place the system in operation until a Certificate of
Compliance has been issued by this Boar f a
Signe UDate
40,1112-
Application Approved by Date
Application Disapproved by Date
for the following reasons
A on
Permit No. Date Issued
No. /X��ll� CC o/ Fee. V
THE COMMONWEALTH OF MASSACHUSETTS Entered in.compute :+
PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS yes
app4catlon for Misposal 6pstem Construction Permit
Application for a Permit to Construct(•) Repair( )-? Upgrade( ) Abandon( ) leomplete System ❑Individual Components
Location Address of Lot o.S 5-0 /1/lL4 ,mot oA Owner's Name,Address,and Tel No.
psT-E'L(//4-L.t . ,^� STD E 1E CGOhV55
C
. Assessor's Map/Parcel 1 ! /,O - 10-3 j OG.D P71,14 4,T? p 5-Fb1?01Z4sA' r '
Installer's N e,Address,and'Tel.No. S O -f�2,7 Na e ddress and Te.h1o. ;
r i`c s svv F s o 1'/3
Type of Building:
y
Dwelling No.of Bedrooms ., � Lot Size �$ ,��{ �'%S q.ft. Garbage Grinder
Other I Type of Building )�C $1A/; C�L No.of Persons Showers Cafeteria(--I -
Other Fixtures /
Design Flow min.required) �y
( d Design flow provided S d
g q ) gP � gP
Plan Date IF QJ Number of sheets Revision Date l 4
Title
Size of Septic Tank /�$- Type of S.A.S. ^.�CT(7 �IIr,
Description of Soil
J
Nature of Repairs or Alterations(Answer when applicable) 411-1�A
I' Date.last inspected:
Agreement:
~ _,T,hgundersigned 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 andt not to place the system in operation until a Certificate of
Compliance has been issued by this Board f H al
Signe Date
Application Approved by Ae 14Date 4, ' f
Application Disapproved by Date
for the following reasons
A Of
Permit No. Date Issued [0 ... � ^r
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
I
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( V11R4aired( ) Upgraded( )
Abandoned( )by
at S'-�f`,� Z d�'J JZ L has been constructed in accordance
with the provisions of and the for i�'osal System Construction Permit No. d 01�- 1" f dated
Installer Designer S�w wa ,, lot,
j #bedrooms Approved desi ll-o v 0 gpd
The issuance of th' pernjit shall not be construed as a guarantee that the system will ctio /as designed.
Date Inspector
- r - - - ---
- ---------------------------------------
I f (�
No. 1 10` �v Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Mispo Y *pstem Construction 3permit
Permission is hereby granted to Construct( Repair( ) Upgrade( ) Abandon( )
System located at Q �• �L/.tom 0 ST")g 2[//�
and as described in the above Application for Disposal System Construction Permit. The applicant reco"g-nized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Pr vided:Construction must be completed within three years of the date of this permit.
Date C� �( " t �j Approved by
l i
Townlvf Barnstable
Regulatory Services
Richard V. Scali;Interim Director
MAS Public Health Division
039.
�o► " Thomas:McKean;Director
, a
200 Main Street,Hyannis,MA:02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&'Designer Certification Form
Date: �3 a Sewage Permit# a o t 6 Q Assessor's MaplParcel N q 4910 f C"G 3
Designer: Installer: `13vf-ZN�!' 1S!C 1A11 ,4
Address: FN(;rNFRR tNyG INC Address _ ��.ilk 10VL tr 4'wU VAT,
•i
� P:O. Box 16
On
�J u Q.('1 F J CV-da.u I.TClJ5was issued a permit to:install a .
(_ate) (installer)
septic system at < M 'LL based on a design drawn by
.(address) -
` t� � - lzd C L ,' ks—
dated
/ (designer)
Y 1 certify that the septic system referenced above was installed' substantially according to
the design;.which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that'the septic system referenced above was installed with major changes(i.e.
greater than 10' lateral relocation.of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip.out (if required)was inspected and the soils
were.found satisfactory.
L.certify that t4e system referenced above was.constructed fiance with the terms
of the IAA ap oval letters(if applicable)
( nsta er's'Signature) '
,.�s�'V✓ E.;°'LAG/(.,/�
(Designer's Signature) (Affix.Designer s Stdmp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:1Septic\Designer Certification Form Rev 8-14-13.doc
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FOUNDATION NOTES: 3.DOUBLE FLOOR JOISTS UNDER ALL PARALLEL PARTITIONS. i� 8. SEE STRUCTURAL DRAWING5 FOR LOCATIONS OF ALL 5TRUCTURAL COLUMNS. K F
1.MAIN FOUNDATION WALLS TO BE I0°POURED CON u
C.W/2 k5 BARS TOP AND BOTTOM REST 4, GARAGE CONCRETE 5LA5 TO BE 4"POURED CONC.ON COMPACTED FILL, CUT JOINTS 9. CONTRACTOR SHALL NOT SCALE DRAWINGS FOR DIMENSIONS. ANY MISSING,INCORRECT,
FOUNDATION ON I O•X20"STRIP FOOTING. ALONG WALLS AND BEAM COLUMN LINES. OR QUESTIONABLE DIMENSIONS NOT BROUGHT TO THE ATTENTION OF THE DESIGNER BECOME
PROVIDE 3 k5 HORIZ.BARS CONTINUOUS IN STRIP FOOTING 1V./KEYWAY. PROVIDE k5 VERTICAL ) THE RESPONSIBILITY OF THE CONTRACTOR. DATE: O6/07/2016
DOWELS @ 24°O.C.HORIZ.EXTENDED 3'-G-MIN,ABOVE TOP OF FOOTING, PROVIDE 5/8'X)2' 5. CONTRACTOR TO PROVIDE BA5EMEN1'VENTILATION AS REQUIRED BY CODE(WINDOWS AND
ANCHOR BOLTS @4'-0"MAX. MECHANICAL). 10. GARAGE AND OTHER FILLED FOUNDATIONS: 10•POURED CONCRETE WALL W/2 k5 TOP AND
2. ALL STRUCTURAL STEEL COLUMNS TO BE 3-1/2'CONCP.ETE FILLED LALLY COLUMNS OR BOTTOM BARS. REST FOUNDATION ON 20°X L 0'STRIP FOOTING. PROVIDE 2 @ k5 SCALE: AS NOTED
T5 4X4X.250 TO EXTEND TO FOOTING BELOW. PROVIDE G"X G"X V"CAP PLATE AND 7'X 1 2"X%" G. CONTRACTOR SHALL ENSURE THAT ALL FOUNDATION WALLS MAINTAIN 4'-O°MINIMUM CONTINUOUS HORIZONTAL BARS AND KEYWAY IN STRIP FOOTING. LAP TOP EARS TO MAIN WALL
COVERAGE. BARS. PROVIDE TRANSITION REINFORCING W/k5 BAR5 SPACED @ 12"O.C.VERTICALLY.
BASE
PLATE W/2 @'Y,'DIA.DOLT5.WELD ALL CONNECTIONS. FOOTINGS TO BE3G'X3G'X)2' - PROVIDE •X 1 2°ANCHOR BOLTS @ 4'-0'MAX. DRAWING p:
SQUARE CONCRETE W/3 k5 SAR5 EACH WAY. OR 4'X4°X.25'TUBE STEEL WHERE SHOWN. 7. PROVIDE WEB STIFFENING PLATES AT EN05 OF STEEL BEAMS.TYPICAL..
A5 - 8
ACCESS COVERS MUST BE W/THIN g` MINIMUM.
1 v DES l GN CR l TER l A : i N VER T EL E VA T l ONS : 6" OF FINISH GRADE
DESIGN FLOW: INVERT AT BUILDING 25.5 32.0 3' MAX/MUM COVER
FIRST 2' TO
4 BEDROOMS AT l l0 G.P.D. PER INVERT IN SEPTIC TANK: 25.0 FIRST
LEVEL MIN 2* OF PEASTONE
BEDROOM EQUALS 440 G.P.D. INVERT OUT SEPTIC TANK: 24.75 OR F I L TER FABRIC
RIVER RD LOCUS NO GARBAGE GRINDER INVERT IN DIST. BOX: 24.57 4` D1AM PIPE 25.2
3/4" - l 1/2" D/A.
Bump INVERT OUT DIST. BOX: 24.4 0 °
22
25.5 24.75 24.4 T2 DOUBLE WASHED STONE
1 NVER T 1 N LEACH CHAMBER: 24.2 y Gas ° ° 2
SEP T 1 G TANK REQUIRED: BAFFLE 5.0 24.57 � 24.2ol
440 G.P.D. X 2UI - 880 GAL. BOTTOM OF LEACH CHAMBER: 22.2 3 OUTLET 3-500 GAL LEACHING CHAMBERS
9�+ ADJUSTED GROUND WATER: N/A 'P D-BOX W14• STONE AROUND, 12.8'r x 33.5'1 x 2'd
SEPTIC TANK PROVIDED: 1500 GAL. MIN.
N/A I500 GAL H-20
opv � OBSERVED GROUND WATER:
SOIL ABSORPTION SYSTEM REQUIRED: BOTTOM OF TEST HOLE #4: 13.5
SEPTIC TANK 6" CRUSHED STONE OR
DESIGN PERC RATE C 5 M/N/I NCH
COMPACTED BASE
o� SOIL TEXTURAL CLASS - 1
OEFFLUENT LOADING RATE - 0.74 GPDISF PROF l L E : NOT TO SCALE
440 GPD / 0.74 GPD/SF - 595 S.F. REQUIRED
PROVIDED: 3-500 GAL LEACHING CHAMBERS
W14' STONE AROUND, A-614 S.F.
LOCUS MAC' 614 S.F. x 0.74 - 454 G.P.D.
GENERAL NOTES : SOIL TEST P l T DA TA+9
INDICATES INDICATES
PERCOLATION - OBSERVED
TEST GROU90WATER
1. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
OF THE SEWAGE DISPOSAL SYSTEM AND PERMITTING rP s1 P*14684 TP s2
PURPOSES ONLY. HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR
0` 27.5 0" 28.7
2. VERT I CAL DATUM /S APPROXIMATE NGVD 29. FOR 0 0
4 - - - - - - - - - - - - - - - 27.2 4 - - - - 28.4
BENCH MARKS SET. SEE SITE PLAN. AIE LOAMY IOYR AIE LOAMY IOYR
SAND 4/2 SAND 4/2 S,
/0* - - - - - - - - -
- - - - - - 26.7 to, - - - - - - - - - - - - - - - 27.9
3. ALL CONSTRUCTION METHODS AND MATERIALS AND
LOAMY 7.SYR LOAMY 7.SYR
MA/NTENANCE OF THE SEPTIC SYSTEM SHALL B SAND 4/4 B SAND 4/4
CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL 24• - - - - - - - - - - - - - - - as.s 26" - - - - - - - - - - - - - - - 26.5
�dr,��F
C I NEDIUW IOYR C/ AIEDIUv IOYR
BOARD OF HEALTH REGULATIONS. SAND 5/8 SAND 5/8
44'
4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER ,
AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER w AO E
THAN 3' IN DEPTH SHALL BE CAPABLE OF W/TH=` - s A8 G
STANDING H-20 WHEEL LOADS. 120" Na warER 17.5 12 . NO WATER /8 7 6�`2b-
TP t3 TP +4 ,
5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
APPROVED EQUAL.
0" HORIZON TEXTURE COLOR 26.2 0" HORIZON TEXTURE COLOR 25.0
0 0
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED 6" - - - - - - - - - - - - - - 2.5.7 6' - - - - - - - - - - - - - - 24.5
PRECAST CONCRETE OR APPROVED POLYETHYLENE. A/E LOAMY IOYR AIE LOAMY IOYR
SAND 4/2 SAND 4/2
BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER 12" - - - - - - - - - - - - - - - 25.2 12- - - - - - - - - - - - - - - - 24.0
TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE B LOAMY 7.SYR B LOAMY 7.SYR
SAND 4/4 SAND 4/4
OUTLET. 28" - - - - - - - - - - - - - - - 23.9 28- - - - - - - - - - - - - - - - 22.7
Cl AAEDI IAII IOYR Cl MEDI UM IOYR ooi
N
7. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. 40• SAND 5/8 SAND 5/8
I-888-DIG-SAFE AND THE LOCAL WATER DEPT.
FOR LOCATION OF UNDERGROUND UTILITIES.
1
8. SEPTIC SYSTEM /NS TAL L ER SHALL NOTIFY THE 132" NO WATER 15.2 138" NO WATER 13.5 �.
DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION DATE
OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE TEST Y:STE. EN H
TEST BY: STEPHEN HAAS �..
CONSTRUCTION INSPECTIONS. WITNESSED BY: DAVID STANTON �"' �y VS' !✓ �+
9. ALL UNSUITABLE MATERIAL (A d B HORIZONS) PERC RATE: 2 M/NIINCH ` ` "� �Tr 4gs�MENT
ENCOUNTERED BELOW THE INVERT OF THE LEACHING
FACI L I TY TO BE REMOVED FOR A D 1 STANCE OF 5'
AROUND AND REPLACED WITH SAND IN ACCORDANCE
WITH TITLE 5.
/0. NO DETERMINATION HAS BEEN MADE AS TO
COMPLIANCE WITH DEED RESTRICTIONS OR ZON/NG
REGUL A T I ONS. I T SHALL REMA/N THE CLIENTS
2
RESPONSIBILITY TO OBTAIN ALL PERMITS. SPECIAL
PERMITS. VARIANCES ETC. FOR THIS PROJECT. OM. ORB FND
EL-36.45
I l. IT SHALL REMA/N THE CL I ENT'S RESPONS I B I L l T Y
TO HAVE THE PROPOSED BUILDING FOUNDATION
DES 1 GNED TO ACCOUNT FOR THE EXISTING GRADE LOT 2 B
AND SOIL CONDITIONS AT THE LOCATION OF THE 98, 148+ S.F.
PROPOSED BUILDING.
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JOB NO: 14-090 40 PROPOSED CONTOUR 0 /0 20 40
JUN 20 16 ANi8:8?