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HomeMy WebLinkAbout0086 OLDHAM ROAD - Health 86 Oldham R6ad (Ostervilk) A=120 i C 9 - No.�....2. ' .. •� �. „ Fizic......L...s... THE COMMONWEALTH OF MASSACHUSETTS c-� BOAR OF HEALTH evN... ............OF .........A�rilld f H. .........................................le ......... Apphration -for 4 ivviial i9orks Tutuitrurtion Vinutit te(3 Application is hereby made for a Permit to Construct (11�or Repair ( ) an Individual Sewage Disposal Syst at _ - -------- ----- ocatisajAddres or of- Je 1(4-12 ner s Ad je.r/ f/ Installer Address Type of Building Size Lot...::__._��_. ......Sq. feet u V Dwelling—No. of Bedrooms---------- ............................Expansion Attic ( ) Gar/age........ Grinder (NO) Other—Type of Building ---___--------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W Design Flow........../_®....................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width.-____---_.... Diameter........___..... Depth...._._--_---_. x Disposal Trench—No..................... Width-------------------- Total Length--.---_---___-•_--- Total leaching area.-_.-_-___-_ -----sq. ft. Seepage'Pit No../_-/ Diameter.................... Depth below inlet...... __... otal leaching area..-----_.-- 1._____sc tt. C � 3-s ,�IlwaentAn 7 z Other Distribution box ( ) Dosing tank ) .� ��'Percolation Test Results Performed by._____....= ��___'�_we.............................. Date•-• .._ LO.-72 Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ Test_Pit No. 2................minutes per inch Depth of Test Pit.................... Depth.to ground water-------------------- ---------------- .... W / 'ODescription of Soil----••-•-------� -- ----•- ..•- ---Yr--•-- _•---------•-Ode•------•----------••-------•--•-•---------------------------------- x ` W •------------- -------------------------------- --------•----------------•----_-------•--------•---------•----•-------------------------••--•--•-•---•-------•--•-••---•------....._._..._....._..------ UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------_------------------------ ----------------------------------------- --•-••----•----------•-----.-.-.--------------------------------------•-----------------------•--------------•-------•-••-_---•-••---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI 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 health. Signe �� •. '' � Date Application Approved By-------- ---- •• ---------------- 8� °-77--------- PP PP f following --------------------------------------------------------------------------------------------------------- Application Disapproved or the ollowan reasons:_._. i . f Date ,;. Permit No.--••----•-••......-----•----- Issued ..... `- -------------------------- -----�--...--------------------------.. . Date l.. v„•mow ... '''07 FRs No.. .....d....:.......!"'� THE COMMONWEALTH OF MASSACHUSETTS. F. BOAR OF HEALTH c.v Al. . / FI .....-1c. ........ ............ ...... Apphration -for M_q Mid Morkii Tonstrurtion Vrrutft � Application is hereby'made for a Permit toConstruct (!/11*'or Repair ( ) an Individual Sewage Disposal System at .: .............119M__ '-----_-----= ----t",--yr/f---- _ �_ ...Ymn.-•-Addres or t oy� ....... / rU�P f �.... � � ��Ys 1 • �/� �7 /i ! Owner Ad ess Installer Address t d Type of Building Size Lot.....10 Sq. feet V Dwelling—No. of Bedrooms---_•___ ____________________________Expansion Attic ( ) G rbage Grinder (tV) aOther—Type of Building ------_--------------------- No.'of persons............................ Showers ( ) — Cafeteria ( ) dQ' Other fixtures ----------------•----____--------••-•--------------- ---------....._.. ____-___-•---•--------------•-------•--------__---- Desi n Flow_.__...___ .".4--__ _______gallons per person per day. Total daily flow_________________________________ ... Mons. W g ,�--- - - --------- g# P P P Y• Y _...... g� WSeptic Tuck—Liquid capacity---:--------gallons Length_____'';________ Width................ Diameter................ Depth-_--_______--- x Disposal Trench—No_____________________ Width-------------------- o,a1 Length___.._.___.__.____.. Total leaching arcs_.---__:----- - _____sq. ft. Seepage Pit No,f _1 Diameter ______________ __ DepMlelow inlet______ ____ otal 1g�chinl e=t:__- .._ _______sq. it. Distribution box Dosing tank Z _��� Dtam` (`; ) •.- B�`✓" � 3�� Other D - w_. W Percolation Test Results Performed by____________________.....-..-•=-.............................................................. Date_____ -aeA4w----;L4..72 ,a Test Pit No. 1----------------minutes per incli':} Depth of Test Pit.................... Depth to ground water..--___--_-______-__--_ G14 Test,Pit' No. 2.................minutes per inch Depth of Test Pit-_-_________________ Depth to ground water.......____________----- ,► --------•---•-...-•-•-•-- Description of Soil -"- 1�� ----- f'�'�'� ----- --- --------- x s U = W r_) —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 o rticle YI of the State Sanitary.Code—The undersigned further agrees not to place the system in ' operation until a tertificate of Compliance has been issued by the board of health. `. Signe ----- "'--- _ - •---••--__.k- 1! ----J --•-% .................... = _ _. ate Application Approved BY------ � = . -------------- ---r/--n"----77----•-- D to Application Disapproved for the following reasons:--•-•------ ---•--=--------- ---------•--------•-------•--•--•------------------•••---•-------•---------------•- ...............•-••------•-••---•---._.._____._...--•------------._.._..----••------------•--•-------•---•----------••--••••----•--...-•••••---••-••. ------------------•••-• -------------------------- Date PermitNo......................................................... Issued-- --•------••---•---•--•----....................... i..r. ..•` - Date - THE COMMONWEALTH OF MASSACHUSETTS BO•A-RD 9' ', ;,: HEALTH 4o. .. OF.... ...... THIS� I T CE IF&That the Individual Sewage Disposal System constructed (�) or Repaired ( ) Y = `- „-------4Y ..... ------ - ------------------------ InstalIe y. } --;-- has been installed in accordance with the provisions of : 4. ' I p he State Sanitary C deb a dfrs_ri)�pin the application.for Disposal Works Construction Permit No_________________________________________ dated-_-____.__.: _................................. THE IS15UANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE f SYSTEINhWILL FU CTION SATISFACTORY DATE - Inspector x. ;THE COMMONWEALTH OF MASSACHUSETTS t BOARD O HEAL t ' : /V d� si�rr ' .......... ...OF........................:............:.. ^ "..:-.'t................._.... 11�...- No.................. FEE......... 'Bi'spolitt r ii rurtion Vrrmit n Permission is ereby granted_ " • r --- to Con t or Re i an Individu Sewa S "s t e t ' at No::-_¢ ._ rtstm ................................................ ---------- -------- -.i� --- U'tN.. *7--- tp-2 Qr 7 7-as shown on theapplication for Disposal Works'Construction Pated.__.. _________________-� --.. �r�Yl � Board of Health DATE..... f: �. '...-:- ..................................----- FORM 1255 HOBBS:& WARREN. INC.. PUBLISHERS" tiS`2oo V 1,AGc G^, L_ . L_6hCH P i1 I JIA a ExTA nA v- N I FOUND, ' 4 L ! 1 I f+Ot HART G� a w� 9N4 ; �'� ` CEQTIFIED pLdT Pt..4.Vj Oft sutra` LOCATIOt.1 05TE2x/ ' LLG SCAL� `��: �C� t>A.T6 5/1-7 /7 7 I C6GZTIFl{ TI-IA-r TI4Ef-oVADAT1orJ 5► aQW P'LA�-j REFEiZ�t.iGE Wtre(-=0 4 CaV\PL%,(S WIT" THE 51 VTE-LI WE L 07 3� A.WC> SETIDACK REQuItZEME"TS OF THIS -TOW Li op 5^ NS AQL � � DATE BA)(TE2 4 �JYE t•.ic_ REG15TGUZSCS LAIJ� SU2UcYotZs THIS VLAW IS VOT BASE') U1"4 A&J OSTEV-VILLE o MC/t.SS. ttJSTQ(JMEtJT SUiZ%/Ml( 4 Tt-tE 06rC75EirS ',+40stil.3:) APPLICANT WoT 6E USGO To .OL'TE2M1l.18 Lo-r Ltwe,5 =—r TOWN OF BARNSTABLE L.00A "I`ON K(o Old 14 AM SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I aM GA). LEACHING FACILITY: (type)' (size) GX NO OF BEDROOMS 3 BUILDER OR OWNER QDS2 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site,or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by,� `r��� ScfS�i< L/tson yIa-7/aOD Al- gl- a�a- OF as 13 - 3 a 03- 33 O 3 C-_.., LOT N%). ADDRESS : g( d(T) lhv°tm ea oft Lv�11� 014NERS NAME : SEWAGE PERMIT NO. : NEW: REPAIR: CCyrJ DATE ��-D.:. ot. �j DATE INSTALLED: c TALL R c, NAME : INSTALLATION OF:L(��Vcpl WATER TABLE.: � FINAL INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE: 3 � e '" TOWN OF BARNSTABLE LOCAno,N _._. SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by toOcATION �� / SEWAGE PERMIT NO. d u 'h, ��c� 2 �3 VILLAGE a.!;' /�Y INSTALLER'S NAME & ADDRESS r c,A -4 r T 7-4—-- 1.3 og BUILDER OR OWNER Apr L�o zt�o S' DATE PERMIT ISSUED DATE COMPLIANCE ISSUED -. 7 i Z� ra `f '7© ., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Vol untary_Assessments M 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name/ information is required for every Osterville✓ MA 02655 5/19/15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, G use only the tab 1. Inspector: I Dqw key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company � Company Name 14 Teaberry Lane i5i U1 El T 61, 1 Y I Company Address Sandwich MA 02644 City/Town State Zip Code (508)477-0653 S113747 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 Further Evaluation by the Local Approving Authority 5/19/15 Insp Vsig3 > Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 86 Oldham Road Property Address I Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 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-3/13 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 M ." 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 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 El due or ponding of effluent to the surface of the ground or surface waters El 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 El ® Liquid depth in cesspool is less than 6" below invert or,available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) r 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- 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 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 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•3113 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 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. City/Town 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? j ® ❑ 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. El ® 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of.Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 86 Oldham Road _ Property Address Alvin Pofahl ' Owner Owner's Name information is required for every Osteryille MA 02655 5/19/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: t Number of current residents: 0 Does residence have a garbage grinder?' ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection E 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)): q see below Detail: 2013 = 94,000 gals 2014 = 101,000 gals Sump pump? _ ❑ Yes ® No Last date of occupancy; 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information 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: 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 21 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.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank(locate on site plan): 12 Depth below grade: -feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: t5ins-3/13 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 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. Cityrrown 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 32" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scram to bottom of outlet tee or baffle .14° How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order. Tees present no sign of back-up. Liquid level equal with outlet invert. F , 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 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 ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. CitylTown 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 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.): no d-box. 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: a t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�' 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6'x6' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Water. level was 5' below invert-stain line was 2 1/2' below invert. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts AMI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.' 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 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.): 4 e 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.): k t5ins•3113 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 `( 86.Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every, Osterville MA 02655 5/19/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage ,disposals stem including ties to Y 9 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 -DCr_V_ I M-= 7 A2z 10' A3= 3 , , o J t5ins-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 .�' 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 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: > 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: Previous inspection report where topo maps were used ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Previous inspection report where USGS topo maps were used 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Oldham Road Property Address Alvin Pofahl Owner Owner's Name information is required for every Osterville MA 02655 5/19/15 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 r f • f„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville NIA 02655 09/07/12 s„ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information , filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not I C7 use the return Michael Kellett key. Name of tflspector ; Aardvark Environmental Inspections , a �y Company Name ^A PO BOX 896 Company Address East Dennis NIA •02641 Cityfrown State Zip Code 508-385-7608 SI 3742 Telephone Number Ucense 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 CIVIR 15.000).The system: 0 Passes ❑. Conditionally Passes ❑ Fails i ❑ Needs Further Evaluation by the Local Approving Authority 09/10/12 Inspector's Signature Date. The system inspector shall submit a copy ofthis 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 approvi11 ng authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system.will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official InspVfionburfc.Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 86 Oldham Road lug.1 Property Address Henry Padula Owner Owner's Name information is Ostetville MA 02655 09/07/12 required for every page. Cityfrown 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"orthe septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfltration 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•11/10 Title 5Offcial 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 Voluntary Assessments 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is Ostervdle MA 02655 09/07/12 required for every Cit /Town State Zip Code Date of Inspection Page. Y P Pe B. Certification (cont.) 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 El Y El N 0 ND lain below): ❑ distribution box is leveled or replaced ❑i Y ❑: N ❑i. 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 Heap: ❑ 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 mannerwhich 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•i mo Title 6 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 _ 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osteryille MA 02655 09/07/12 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 mannerthat protects the public health, safety and environment: ❑ The system has aseptic 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-11/10 Me 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Fora �l Subsurface Sewage Disposal System Form--Not for Voluntary Assessments 86 Oldham Road ^sty Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 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: ❑ ® 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 otherfailure 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 ebst 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. Ey 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 i ❑ ❑ 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-1WPA)or a mapped Zone 11 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 signficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 50Ricial 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 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. City/Town 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 0 ❑. Pumping informationwas 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? 0 ❑ 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 5 -` =' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yi 86 Oldham Road: Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 Cityrrown Page. State Zip Code Date of Inspection D. System Information Description: f Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes `® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercialllndustrial 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form Not for Voluntary Assessments 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is Osterville MA 02655 09/07/12 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 'General Information 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: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes,attach previous inspection records,if any) El Innovative/Altemative 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts F Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Oldham Road Property Address Henry Padula Owner Owner's Name information a Osterville MA 02655 09/07/12 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 07/08/77 per BOH Were sewage odors detected when arriving,atthe site? ❑: Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.6 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): 1.0 Depth below grade: feet P 9 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: 1,000 gal Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page, City/Town 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 28" Scum thickness 3-0 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence.of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert Grease Trap(locate on site plan): Depth below grade: 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Oldham Road, Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. cayrrown 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 [I 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•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form Not for Voluntary Assessments 86 Oldham Road Property address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present mustbe 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.): No box present 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.): Soil Absorption System SAS (locate on site plan,excavation not required): If SAS not located;explain why: t5ins-11/10 Title 5 01Txial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yi 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. City/Town 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/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 6'x6'precast pit.There was 25"between th inlet invert and the liquid. 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.' t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form,-Not for Voluntary Assessments y � 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. Cityfrown 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.): t5ins•11/10 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Mix Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. CAyfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 E drawing attached separately as 33 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts P- Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville WA 02655 09/07/12 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: 20.0 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: USGS maps shows an elevation of over 20.0 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11ltf) Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of'Massachusetts Title 5 Official Inspection iForm Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments y� 86 Oldham Road Property Address Henry Padula Owner Owner's Name information is required for every Osterville MA 02655 09/07/12 page. CityRown 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 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: 86 Oldham Road Osterville, MA 02655 Owner's Name: Rose Piper Owner's Address: Same Date of Inspection: April 27, 2001 Name of Inspectori'(Please Print)•James`M. Ford Company Name: James M. Ford P e� Mailing Address: P.O. Box 49 RNg1 P Osterville,MA 02655-0049 LDS HEP eN P�. i20 Telephone Number: (508)862-9400 Parcel. 111 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 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: s ✓ Passes Conditionally Passes N=ds Further Evaluat:On by the Local App::d:ig_A-:t ority- • tl . Inspector's Signature: r*` ' Date: April 28, 2001 The system inspector shall subm' 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. _ Notes and Comments ****This reporf only describes-conditions'ai f th trine 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 Form 6/15/2000 page 1 qv,- , Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 86 Oldham Road Osterville, AM Owner: Rose Piper Date of Inspection: April 27, 2001 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;updn completion,ofthe-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 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. 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 pipe(s)are replaced obstruction is removed 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_ofthe.Board of Health):..,.__,__. broken pipe(s)are replaced obstruction is removed ND explain: 2 \- - - - - _- Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFIC'ATION (continued) Property Address: 86 Oldham Road . ... . . .._ _.. - ' Osterville, MA '_. Owner: Rose Piper Date of Inspection: April 27, 2001 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 System viill fail unless"the'Board of Health'(and Pdblic Water Supplier,if any.)determines that the. system is functioning in a manner that protects the public health,safety and environment: " I ee'system:has aseptic tank:arid 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 fa 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 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 III Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART A _CERTIFICATION (continued) Property Address: 86 Oldham Road Osterville. MA Owner: Rose Piper Date of Inspection: April 27, 2001 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 than 'h 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.6f4 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 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.] 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 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. 4 Page 5 of 11 -- OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS -' - - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B :.CHECKLIST Property Address: 86 Oldham Road `___ Osterville. MA Owner: Rose Piper Date of Inspection: April 27, 2001 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? ✓r.: '': :Were as built;plans.of the system:obtained and examined:?(If they,were!not available note a§N/A) ✓ Was the.�facility-or-dwelling-.inspected:for•signs of�sewage:back up.?i_ .;,. . ,•:,� . : ✓ :-Wa§the site,-inspected for signs,of break out?. • y A ` hl-Oro ✓ °.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: 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)13 10 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR YOLUNTARY-ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION FORM '.... PART C -SYSTEM INFORMATION Property Address: 86 Oldham Road Osterville, MA Owner: Rose Piper Date of Inspection: April 27, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: I 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)): 2000-116,000 Aals.; 1999-144,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow..(based.on 310..CMR._15.203):- . pd..._..._._..._... .....................__.__...___...._...__ Basis�6f 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): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on May 9194-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM box,soil absorption stem ✓ Septic tank,distributionx, rp 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 curreni�operation and maintenance contract'(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source.of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 %00 Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART B OJI :CHECKLIST Property Address: 86 Oldham Road v Osterville, MA -` Owner: Rose Piper Date of Inspection: April 27, 2001 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 ` k - ✓ 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 builtplans.of the system.obtain'ed and examined?.(If they.were not available note as N/A) ✓ Was the.,-facility or�dwelling:irispected'for=:signs of�se)yageback up.;. f a `✓ .. 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: 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 CMR 15.302(3)(b)]. nl i. r LL) c ' 41w y t,ti xpf,# a 5 Page 6 of I 1 -OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C : . .SYSTEM:INFORMATION Property Address: 86 Oldham Road Osterville, AM Owner: Rose Piper Date of Inspection: April 27, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Xo 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)): 2000-116,000 gals.; 1999-144,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIA ANDUSTRIAL Type of establishment: Design flow_(based on Basis�bf design.flow(seats/persons/sgit,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): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information- Pumped on May 9194-per treatment plant s - Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 -'-'OFFICIAL INSPECTION FORM - NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C 'LL SYSTEMV .INFORMATION (continued) Property Address: 86 Oldham Road Osterville. AM Owner: Rose Piper Date of Inspection: April 27, 2001 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) Depth below grade: 12" ' Material of construction: ✓ concrete metal _fiberglass _polyethylene------------- _other(explain) If tank is metal list age:. Is.age confirmed by a Certificate of Compliance(yes or.no) (attach a copy of certificate) _ . _.._-------- Dimensions: 1000 gal. , Sludge depth: 21' Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick 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 tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every 3 years 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: . Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _ .. 7 Page 8 of 11 OFFICIAL INSPECTION FORM :NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C '= =`�SYSTEM:IN.FORM'ATI.ON (continued) Property Address: 86 Oldham Road Osterville, MA Owner: Rose Piper Date of Inspection: April 27, 2001 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 Design Flow: allons/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: .: . None :.(if present must be opened)(locate ogsite.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(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 y� Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM :..... . PART C r,.fr7"s--;,-.,,, '':SYSTEM.INFORMATION (continued) 1 Property Address: 86 Oldham Road Osterville. MA Owner: Rose Piper Date of Inspection: April 27, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: r. Type ✓ leaching pits,number: 6'x 6'-1000 gal. 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 vegetafiori, etc.): The pit had 4'of water on the bouom.• The scum:line was•at the same level:'.There were no signs offailure. The bottom to grade was approximately 9'. The cover was 20"down. CESSPOOLS: None (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 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: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 86 Oldham Road Osterville, AM Owner: Rose Piper Date of Inspection: April 27, 2001 Map: 120 Parcel: III 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. _. a A I- � Aa- Ib , . A3- 3I - O 133- 33 3 10 � s Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY:ASSESSMENTS .'SUBSURFACE SEWAGE DISPOSAL.SYSTEM`INSPECTION FORM PART C (SYSTEM INFORMATION (continued) Property Address: 86 Oldham Road Osterville, AM 3 Owner: Rose Piper r Date of Inspection: April 27, 2001 SITE EXAM Slope Surface water Check cellar 4. Shallow wells Estimated depth to ground water 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high;ground water elevation: The bottom ofthe leach pit to grade was approximately 9' Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 40'+/-to groundwater at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 • s OCT 8 ayn� Commonwealth of Massachusetts Executive of Environmental Affairs HP Department of , Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Sc� cv 41A 0- , o z b 5 5 Address of Owner: (if different) Date of Inspection: C: ti y1 Ct Name of Inspector: Michael` DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508)4771420 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 inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system - Passes --- Conditionally Passes --- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s S ignat Date: c:�-\ S The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. �ti. a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8c. Owners : D ate of Inspection : INSPECTION SUMMARY: Check A, B, C,or D A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated",explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ---- broken pipe(s)are replaced ----- obstruction is removed ---- distribution box is levelled or replaced ---- The system required pumping more than four 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 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : gL k� zA, Owner : Date of Inspection : C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health, safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: --- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what.will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: N. Owner: Date of Inspection : D) SYSTEM FAILS (continued) -- 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 over- loaded or clogged SAS or cesspool. --• Liquid depth in cesspool is less than 6" below invert or available_ volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I 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 ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 86 Owner: D ate of I nspection E.) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- 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. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00. Please, consult the local regional office of the Department for further information. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ek QLA . Owner: Date of Inspection: Check if the following have been done : -x Pumping information was requested of the owner ,occupant and Board of Health. -•x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. -•x All system components,excluding the Soil Absorption System,have been located on the site. --•x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facilityand owners occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: RESIDENTIAL: Design flow : 33o gallons Number of bedrooms Number of current residents: a 2 Garbage grinder(yes or no) Laundry connected to system (yes or no): yz 5 Seasonal use (yes or no) : Water meter readings,if available: %-�t K , Last date of occupancy : COMMERCIAUINDUSTRIAL Type of establishment: Design flow: gallons/day 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) : Water meter readings,if available : Last date of occupancy : Other: (Describe) ........................................................................................................:... Last date of occupancy:. GENERAL INFORMATION PUMPING RECORDS and source of information: ..�... .... yr � System pumped as part of inspection (yes or no):.....5 ©....... if yes, volume pomped: .................... gallons Reasonfor pumping:............................................................................................................. � r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8(.. 0" Qsi. , Owner: F•�v►T�w Date of inspection: TYPE OF SYSTEM XSepk tank/distribution box/soil absorption system -- Single cesspool •-- Overflow cesspool --- Privy • Shared system (yes or no)(if yes, attach previous inspection records, if any) - 0 ther (explain). ...... ................................. .......................... APPROXIMATE AGE of all components,date installed (if known)and source of information a.................................................................:.................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site: (yes or no)....lt,� SEPTIC TANK : .... . .. (locate on site plan c� Depth below grade: ....... Material of construction: ... concrete ......... metal........ FRP ........ other (explain) .............................................................................. Dimensions: . x . . . Sludge depth:..5'`....... Distance from top of sludge to bottom of outlet tee or baffle:.......3 y................. Scum thickness:....0.,.......... ,j Distance from top of scum to top of outlet tee or baffle: .......0l....................::...... Distance from bottom of scum to bottom of outlet tee or baffle:....06................. Comments : (recommendation for pumping,condition of inlet and outlet tees or baffles,.depth of liquid level in rela io to outlet invert,structural integrity,evidence of leakage,etc.). I T 1��. .... ....... r , ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `BG Owner: No Date of inspection: GREASE TRAP : ....... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... ................................................................................................................:........................ Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum-to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.)........................ TIGHT OR HOLDING TANKS:.... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ...........................................:.................................................................................................... Dimensions:............................ . Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 G Owner: � �,� Date of inspection: DISTRIBUTION BOX:... (locate on site plan) Depth of liquid level above outlet invert:................... Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into or out of box,etc.).., ................................................................................................................................................ ................................................................................................................................................ PUMP CHAMBER:...�JU.. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ............................................................................................................................................. SOIL ABSORPTION SYSTEM (SAS):......... . (locate on site plan,9 possible; excavation riot required, but may be approximated b non- intrusive methods) pR y if not determined to be present, explain: .........................................................................................................................:...................... Type.......................................... ....................................................................................... leaching pits,number: A aR&.l. leaching chambers, number:........ leaching galleries,number:........... leaching trenches, number ,length:..................... leaching fields,number,dimensions:................... overflow cesspool, number:.......... Comments: (note ondition of soil $' nsof h drauHcrfailure,level of pondin condition of vege 'on, etc . . .. . i G'1�-�.c` .. .. ..... . .. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 126 CApktvw\. QA, Owner: Date of inspection: CESSPOOLS:..... (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ PRIVY (locate on the site) Material of construction: .................................... Dimensions: ...................... Depth of solids: ................. Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.). . H i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 5� b o Owner: Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' �a'p, A-\ Az- as �z- �o DEPTH TO GROUNDWATER: Depth to groundwater: fi. .feet Method of determir}atiapproximatirre: 5,. ................. ....�s., ... ... .......... . ...............................................................