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Commonwealth of Massachusetts
. Title 5 Official Inspection Form
T' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ma
34 Old Salem Way
Property Address P
Jacquline O'Leary ,
Owner Owner's Name
information is X,
required for every Barnstable ...village of Osterville Ma 02655 2/26/2018 �
page. City/Town State Zip Code Date of Inspection '
!Qi j
�ry
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information C �a86p:
filling out forms J
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Peter Galligani
use the return Name of Inspector
key.
Rooter Man of Cape Cod
Company Name
PO Box 306
Company Address
West Harwich Ma 02671
City/Town State Zip Code
508-430-4000 SI 14061
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
Ne ds Further valuation by the Local Approving Authority
r
3/1/2018 _
nspe or's i Date
The ys m inspectors all submit a copy of this inspection report to the Approving Authority(Board
of Hea th 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 off 117740) ,�//�\
Vt ,v
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 34 Old Salem Way
Property Address
Jacguline O'Leary
Owner Owner's Name
information is 9 required for every Barnstable ...village of Osterville Ma 02655 2/26/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
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.
*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):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
r, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is required for every Barnstable ...vg
village of Osterville Ma 02655 2/26/2018
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 (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑
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
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is 9
required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page.. Cityrrown 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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4 � 34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is g
required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
'from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for 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-
1 0,000g pd.
❑ ® 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.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Old Salem Way
L,-
Property Address
Jacquline O'Leary
Owner Owner's Name
information is required for every Barnstable ...village
of Osterville Ma 02655 2/26/2018
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® ❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): unknown Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6/16 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
34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is g required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Septic Tank, Distribution Box, and (1)6'x6' precast leaching pit
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundrysystem inspected?Y p ® Yes ❑ No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 49 GPD
Detail:
2017- 16000 gallons 2016 20000 Gallons 36000/730=49 GPD
Sump pump? ❑ Yes ® No
Last date of occupancy: 2/15/2018Date
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
< � 34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is 9
required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date 018
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Unknown
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
34 Old Salem Way
v�
Property Address
Jacquline O'Leary_
Owner Owner's Name
information is g required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page. City/Town State Zip Code Date of Inspection
Ds System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
8/28/1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):'
Septic Tank(locate on site plan):
Depth below grade: 2feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 Gallon Tank, Cement Baffle on Outlet and Plastic 4' T in inlet. No signs of leaking, no vegetation
intrusion.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
4'x9'4' 1000 gallon tank.
Sludge depth: 14
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is required for every Barnstable ...vg
village of Osterville Ma 02655 2/26/2018
page. Citylrown 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
14"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
2"
Distance from bottom of scum to bottom of outlet tee or baffle
19"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan).-
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
34 Old Salem Way
J
Property Address
Jacquline O'Leary
Owner Owner's Name
information is g
required for every Barnstable ...village of Osterville Ma 02655 2/26/2018
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.):
All components in place, no issues found with tank.
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
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is g
required for every Barnstable ...village of Osterville Ma 02655 2/26/2018
page. City/Town State Zip Code 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 None
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.):
DBox level no signs of carryover, no vegetation, level and water below invert of pipe to leaching pit.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is g required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.): ,
Leach pit dry at inspection. Stain Level 34" below invert of pipe coming into the leach pit.
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. � 34 Old Salem Way
v
Property Address
Jacguline O'Leary
Owner Owner's Name
information is 9
required for every Barnstable ...village of Osterville Ma 02655 2/26/2018
page. Cityrrown 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: N/A.
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
34 Old Salem Way
V
Property Address
Jacguline O'Leary
Owner Owner's Name
information is g
Barnstable ...village of Osterville Ma 02655 2/26/2018
required for every
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
whe a public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
47 Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l;
34 Old Salem Way
Property Address
Jacguline O'Leary
Owner Owner's Name
information is g
required for every Barnstable ...village of Osterville Ma 02655 2/26/2018
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: 29.3 From SAS Bottomfeet
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:
Town of Barnstable Ground Water Contour Map 6/1992
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
Google Maps from Google Earth
You must describe how you established the high ground water elevation:
(1) Site is 47' above sea level. (2) Grade to SAS Bottom is 9.0'. (3) Ground water contour is>5.0
Above Sea Level. (4) Max Rise MIW29C for 6/1992 is 3.7' (5) Seperation Math 47-(9+5+3.7)=29.3'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
,� Title 5 Official Inspection Form
l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�,� 34 Old Salem Way
Property Address
Jacquline O'Leary
Owner Owner's Name
information is 9
required for every Barnstable ...villa a of Osterville Ma 02655 2/26/2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
1
t5ins.doc rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 17 .
` TOWN OF BARNSTABLE
LOCATION SEWAGE#
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VII.LAGE Ui/lam ASSESSO MAP &LOT O �
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SEPTIC TANK CAPACITY IWO
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LEACHING FACILITY: (type) i �/f (size) /000
NO.OF BEDROOMS
BUILDER OR
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility n 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 1 ac ' faci' Feet
Furnished b /
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k�O CA T ION S WAGE PERMIT NO.
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I N S T A LLER'S NAME i ADDRESS
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DATE PERMIT ISSUED 3 -- ✓ 2--
D A T COMPLIANCE ISSUED
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BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop
S' '//e. — - --- - -- --- - -
Date oflnspec} _ Map arce,` -- Owne"--- --- -- r - ---
PART A — CHECKLIST..
CHECK IF THE FOLLOWING HAVE BEEN DONE:
� �/ � S
t/ t'UMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. 0&
19`w
NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE S -TEM HAS BEEN
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BE 1, DUCED INT
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
6-1, AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED..NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
,/ THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
✓ THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
v.ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
!/ THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF SCUM.
l/ THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
/ APPROXIMATED BY NON-INTRUSIVE METHODS.
THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B = SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
No of Bedrooms No of Current Residents Garbage Grinder
Y Laundry Connected to System 6Jeekeac Seasonal Use
NON RESIDENTIAL: -- -—� - -- —
Calculatediflow) _
WATER METER READINGS,IF AVAILABLE: -- " -- - -- ---
Pumping Records and So ce of Infor ation: GALLONS
SYSTEM PUMPED AS PART OF INSPECTION?A/6 IF YES VOLUME PUMPED = GALS
Reason for Pumping:
TYPE OF S M: _
`Septic.tank/distribution box/soil absorption system
Single,Cesspool Overflow Cesspool Privy
Shared system:(if yes,attach previous inspection records, if any)
Other'(explain)
Ap r ximate a of all components: ' -Date installed,if known. Source of information.
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B SYSTEM INFORMATION (Continued)
SEPTIC TANK:: _
Depth below grade: p off Dimensions:
0 lJ • � /� (.p. X J
Material of construction: oncrete Metal FRP, Other}
Sludge Depth. / Distance from top of sludge to bottom of outlet tee or baffle
7
Scum Thickness 6 Distance from Top of Scum to to p of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle
a
Com ants:
s Q ./CY3� q p
Q h II f r,L
— �h�' •
DISTRIBUTION BOX: �� e DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMP CHAMBER: Pumps in working order?
Comments: - — -
SOIIL ABSORPTION SYSTEM SAS
IF NOT PRESENT,EXPLAIN:
TYPE.:� ow 00,
Co ents:
s
CESSPOOLS Number and configuration
Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indicaflon of groundwater Inflow(cesspool must be pumped)
Comments:
04
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B"= SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
0
i
DEPTH'LO GROUNDWATER: DEPTH TO GROUNDWATER
zt:•
METHOD OF DETEFUINATION OR APPROXIMATION
1 .
X vtPAo: � Gl•5, o���fB�'/�'' �8�� /�
ve
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C - FAILURE CRITERIA
/ (Indicate Y-yes N-no ND-not determined.Describe basis of determination.If"not determined",explain why not.)
/ Backup of Sewage into Facility?
�( Discharge or ponding of effluent to the surface of.the ground or surface waters?
Static liquid level in the districution box above outlet invert?
Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
Required pumping 4 times or more in the fast year? Number of times pumped
Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration?
tank failure imminent?
Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
Within 50 feet of a surface water?
Within 100 feet of a surface water supply or tributary to a surface water supply?
Within a Zone I of a public well?
Within 50 feet of a private water supply well?
Within 50.feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the.SAS)?
.Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality.analysis? If the well has been analyzed to be acceptable, attach
y p a h copy of well water analysis for
coliiform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D -CERTIFICATION
INSPECTOR -ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS
COIVIPANY: BORTOLOTTI CON
STRUCTION INC. MA 02648 (503)771_
9399
CERTIFICATION STATEMENT
1 CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
REPORTED IS TRUE`ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE:PROPER,FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS.
CHECK ONE: .
1/ I HAVE
•_ E NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
HEALTH OR THE-ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR'15.303. THE BASIS FORTHIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
FORM.
INSPECTGR'S SIGNATURES '
DATE: 3 p
ORIGINAL 1 O SYSTEM OWNER,•.COPIES:.BUYER(if applicable),APPROVING AUTHORITY
No._,.. .._...._ : ;_ FEs............................Y x
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oF...... �.kjj;s �J,Lk ------ ...........................
l ......---... .
rpliration for Di-spoo al 00 Tonaturtion ramit
hz
Application is hereby made for a Permit_to Construct ( Q) or Repair ( ) an Individual Sewage Disposal
System at: .l
w.........1n . ......_0..s..f�.... ..........' ' ..... .-... ....
------------------- ...._........------
cation ddress " or Lot No.
p y
-` -C ?.................
��� ------------------••----.........----..............
v
Own Address
8-�- ------------_-------------- f -'.--------------.....................---=
Installer �`` Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms._..._ •..................Expansion Attic (IUp) -Garbage Grinder WO)
p-, Other—Tyype of Building .:_. No. of,•persons.....5._.__................ Showers., Cafeteria ({/
Other fixtures ...... i
W Design Flow........_57.5`..........................gallons per person per day. Total daily flow.... .. . _......................gallons.
9 Septic Tank—Liquid capacity-j��allons Length----AJ....... Width---lc.......... Diameter-----�_.:..... Depth...._..._..
�,/f Disposal Trench—N°. & . Width.................... Total Length.................... Total leaching area__-?_fie C.......sq. ft.
z„
Seepage Pit No....liU4 . Diameter.................... Depth below inlet.................... Total leaching area-.................sq. ft.
=; z Other Distribution box Dosing tank ( )
pp _.__
Percolation Test Results Performed by....C_�_�Cl?. .......... .... .. 6.� V Date_.......•...........•...___.--......_..
Test Pit No. 1...1:.Zminutes per inch Depth of Test"Pit.................... Depth to ground water....
fZq Test,Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------------- ------------------------------------------••-•----•--•----•---•--...-------------.-............-•-----------------•---•-•----••-•--------.-----
0 Description of Soil........................................................................................................................................................................ ..
U ••••--•-•-•--•---••------•••••••••-••-------••--•-•...--•------...••--••---------•••-•-.......-•--•-----••------••-•••••••••--•----••-•-----•--••--••--•-•-•-•-•••••••--••-------••-----•-•---•---------
W
---------------------------------••-•--••---------------•-------------•----•....-•---•----•••......---••-•-•--•-•----•-••••----------••...........---•-••.............................................
U Nature of Repairs or Alterations—Answer when applicable.............................................................................................. <
••-•---------•-•••---•••-----•--•-•---------•-•--•-•••••--•-----•---------------•••-...•--•-------------------•-•-•••-•---•--•-•>......-•-•-•••-•-•---•--••----......------.....••--
Agreement:
The undersigned agrees to install the aforedescribed,Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the Stat nitary Code—The undersigned further agrees not to place the system in
Nperation untN C i sate of Compli e has been issued by the board of heal
Signed i.... ....
. — _ ...
plication proved BY ��-----•-- vas J
( .....------••.....-----•-------•----•---
Date
Application Disapproved for the following reasons:.................................................................................................. ----------
..•-•---.....--•----•---•-•---•••-•---••••-•---•--------••••------•-•-•....•--••......---...••--•--•-•-----•._.....-•-----•-••-•-•-•--------•---•-•-----••.............................................
Date
PermitNo........................................................ Issued.............................. -------------------
Date
= = ---- - - - s - - - ---------------
rN �p �- .. Fizz...............1:.�..-24
o._.
THE COMMONWEALTH OF MASSACHUSETTS X
BOARD OF HEALTH ==-
I_v ..................OF.....: -:.
e. Applira#ion for Disposal Works Tonstrurtion rrntit ;
t; �Application is hereby made for a Permit to Construct (C- ) or Repair ( ) an Individual Sewage Disposal
System at: ;>
3
........... s:�... :....--------•-•-. � .................................:.....`... .....
�oca� onAddress or Lot No.
c j t ••--•...... A-----------•---•--•---•--------------------------•-.---
or r G Ow s Address x
M Installer Address
UType of Building Size Lot.................... ......Sq. feet
�-, Dwelling—No. of Bedrooms_...___-11-------------------------------Expansion Attic Pp) Garbage Grinder Wp)
ahOter—Type of Building ". . .?..... No. of persons.....`am.................. Showers ) — Cafeteria fij,))
Otherfixtures 4) -------------------------------------------------------------=--------------------------------•----------•---------------------
w Design Flow....._.?. :............................gallons per person per day. Total daily flow--------3&-C.)........................gallons.
WSeptic Tank—Liquid*capacity_ allons Length.../P........ Width._/.......... Diameter____ ........ Depth. _.........
x Disposal Trench—No j C%_.?__.. Width.................... Total Length.................... Total leaching area_w24.'_.......sq. ft.
..
Seepage Pit No._-/_1��. ._:_�•. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (fie) Dosing tank,,( )
aPercolation Test Results Performed by.- .1 12 c _ '00449.t!j? Date........................................
Test Pit No. 1........ -__.minutes per inch Depth of Tes Pit.......... Depti to ground water.._
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 G4 ..--•---------------------------------•---------....------•••-----...-----...--------•-••••-•-••.......•----•••••------•••...._•-------•---...._...•---......
Description of Soil.........................................................................................................................................................................
x
c,
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•-------••------------•-----....-----------•----------------•-•--•-•--••----•-•-•----------------------------------•-------•--------------------------------•--........----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a.Certificate of Compliance has been issued by the board of heal h. /
-`
t /-at/e
ApplicationAppr ed By............. •----•--------------------•-------.....-•----•.......---•-•-•---.....--•-----• ---------
Rate
Application Disapproved for fhe,following reasons:-----•--------------••-•---•--------...---------------••------...---------------•---=- --
.............................----•------••--------••--------.....----------•-----...-----...-----.......
I • Date
}Permit No.......................................................... Issued_.......................................................
Date
T
R THE"COMMONWEALTH OF MASSACHUSETTS r
BOARD OF HEALTH
....... ir...............OF.....
,,, E/� «. lzf' .....................................
Trriifirab of Tontplianrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed 5,cj or Repaired
b . lf.. f =----------------- --
In taller
at........ --� •-------.. �C�f-_..4 rSrr. -----W 2211 ............'''� ?
has been installed in accordance with the provisions of TITI� 5 of The State Sanitary Code as described in the
application for Disposal Works Construction.Permit No.-� _----------------- dated------- -".' .-!_"'__$'„�,.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UE® AS A GUA NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
l
DATE...............
... ....................................... Inspector.............. .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�`No. i ..._...// -• /4.' t17�2 . OF.. x. �? . . ...........................
✓ FEE........................
Dispolia Works Tomiy inn rrntit
Permission is hereby granted..------ -- r7f -a =--•-----------------••-----------•-----.....-----••----...........--•-•----.•..
to Construct,(,V ) or Repair ( ).an Individual Sewage Disposal System
0
at No. � .�� S _try l eq�. - <
7 - -
Street 7 /�4
-•� as shown on the application for Disposal Works Construction Permit ol.................... Dated..............
1
e DATE............... -- 7 __ oard of Health ,.
...
V,...
FORM 1255•�,A.1 M,.SULKIN, INC., BOSTON
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LEGEND
x PLOT PLAN.
' SPOT ELEVATION 0 0
a
EX13T.ING ' ��A oF,Mq R ED
CE TI I
'< > EX CONTOUR —.--- 0 - Y ;
143
k FINISHED SPOT ELEVATION ��; ROBERT?�
FIKI SHED CONTOUR" O --- w tr s T:•
r; Z N
r
APPROVE[), BOARD:' OF HEALTH aY a . A ``!!
y a` +� .. ,0�0 +.
' F r .xDATE AGENT s . ::z � u "SCA :�I»� i� p DATES Z
,� r;� ,,, ... � .. .. .. ��..w �' S 't ;':,tea ?��.a^ ray Yi i '`� '� � .��'• �, { �,�'� �.�•' - ,� ,
GE' ENG/N�E`ER/KG
i>A , CLIENT, i 'CERTIFY THAT THE PROPOSED }
` z; a EGIS'TE R:E RE013TER D °'L J08 a k BUILDINO°a'`'SHOWN ' ON THIS PL AN
a
z s ; .CI:VII: LAND CONFORMS :TO THE ZONING _IAWStt s
, tENO EER RV w #: t?R BY .<— QF QARNSTABI * ,:MASS'
r�a � kj,. .,.. .."� y.y t"• ,.n.� t.'r t.. e '� r 'r ,� ,, t f '�, k iv
�3 ;MAIN: STREETA4 #"-
z t F7. M„k S. 9 rc x's 'r,6__ c s fi:_+t r'*a !•*r s`t .. s sY� ,
MYANNJ:S, MASS.} SHEET �' QF D TE � F RED. -LAND'' SURVEY'4,R
Y
/VOTE /F E/TNER THE SEPT/G TANK DR
G.EACNTivG P/T ARE MORE rM q,,V 1Z"SELO&V
/O PT. M/N. _ GRAIOE� A 24'O/.�IMET.ER CONC•RF7'.E CO6%E.P
K- SWALL $E B APO V-4oWT 7`0 4RADE.�i4N .EX-roleA .
4 PYC /PE S
ti16,14YY C/1 T //P QN CO{/ER SMALL DE USFO
l G./••D CANCI�FTE i M/•�!. PJTCi+% �
+e /— COYE_RS I8'PERFT /F//V DR/✓FNMAY
�� �y»y, CD/VCR2.'�'TE
�A a �_ 'a;,
AOE, CO✓ER CLEAN .SANG
�`• SCHEDam40 1 z*LAYER
P1CC. P/PE /000 o 00 0 0� G1F I8 -3/Bi
GAL. • I I • . • • • • • o •e�
SEPT/C TANK D/ST, o • s I • • . . . . f , . yyA 5 t/FO STGNE
BOX C • .• I • • O I • • .••. -
• .a 1 I •EFFECT/VE ' • , 314
• • • f • DEPTH • • 1 • • v o 1td43NED STO;YE
I Sif-S x 2 S' 471 25 i a, • r . • • • • 1 / P •�y PRECA5T SEdFpAGE'
78'S x P/7 OR EQU/V
IONS i-D " 7$• I • I a o
/NVZAT L`LEYAT/ .
s
2!t9-7S C'ALI Dav� 6 t-r. D/AM.
/NX&A7 AT OUILDING 97•SFT.
INLET SEIaTIC Ti4NK 3 FT, /O FT VIAl+9. � C(SEE TABUL.dT)0N>
O�/TLET SEf�TlC TANK QZLFT. '
/JVLE'T 49J57R/8l?!ON BOX 6 19 FT SECT/ON OF GROUND. J41TER Ti4041-E
OtITLETDJSTRIBtIT/ON BOXY FT
//V46T LEA CH/NG' f=/T 9 G s"FT SZ VVAGsc 01SR SSA L SYSTEM►?
L EACH/NG o/T T�1&ULr4T10N
DES/GN �'R/TER/R -YcALE %+ _ o" DwENSlON A G'�
D/AIHYS/QN 8
NUmdER OF BEDROOMS �_
D/MENSlON G_ FT. M,�
G4aaA6,Eol5Pa05 .L uN/r ML SOIL LOG .SO/L TEST
TOTAL A•,S'T/MA`TEO FLO*V 330 GAL.IDAY SO/L TEST A/ SOIL 7Z 7's la
i1lUMBER l.C`ACNlNT P/TS / FLAY. 99 9 �[tY. -S . PATE OF 80/L TEST 4� /5 lei
S/DEL,EACHING PER PJT 1 fs�ssSQ, .iT. Zi' RESULTS IV/TNESSEO BY�uLMu,aaMr�T.•Jo�Es
BOTTOM LF�ICH/NG PER P/T Sq, pT. P (+ PERCOLAT/ON MATE#/ < 2_ I►7J/1�/JNCH
4--3UQ.:Of l— LO.' m f . <' _,i-.
1 TOTAL LEACH/NG �4REA ESQ. PT. ` P&r#VCOl.AT/ON RATE A MIN.f INCH
RESERVE LE54CN//V6 AREA 2--Z_SQ. FT.
2i ►� >i — /2OF
OLD S A t�.•� �,9 y
/�s B�RrySTAt3Le. MASS
s PHI vw '
INo. 365 /�
ELDREDGEENG/NCR//Z CQ/�C•
t D �T'n z / 82 S G $ 7!2 MAIN 9T.y KYANN/9, MASS-
NGGR00,Vp W,4neR. ENCOUNTERED ,ErL/ENT: SIDE vrTE FB
Q GROUND W,4TER AT ELEY. J06 MVO. 435CO/o SMEl'T�OO z