HomeMy WebLinkAbout0225 OST.-W.BARN. RD - Health 225 OST, -- =W BQ�`l
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Rk 31014 Po245 r1447
01-10-2018 a► 11 c 30cx
CONFIRMATORY
DEED RESTRICTION
WHEREAS, KATE E. COUET of 225 Osterville West Barnstable Road
Osterville MA is
the owner of 225 Osterville West Barnstable Road Osterville MA
located at 225 Osterville West Barnstable Road Osterville MA
thereinafter referred to as and being
shown on a plan entitled Subdivision of Land in
et al,
`duly recorded in Barnstable County Registry of Deeds in Plan
Book Page ;
Or on Land Court Plan Number
WHEREAS, KATE E. COUET as the owner of said lot has agreed with
w the Town of Barnstable Board of Health to a restriction as to the
number of bedrooms which can be included in any home built on.
said lot as a pre-condition to obtaining a disposal works
EL construction permit in compliance with 310 CMR 15. 000 State
: Environmental Code, Title V, Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage; A
ti
�.t :WHEREAS, the Town of Barnstable Board of Health, as a pre-
condition to granting a disposal works construction permit for a
septic system in compliance with 310 CMR. 15.200, State
; Environmental Code, Title V, Minimum Requirements for the
: Subsurface Disposal of Sanitary Sewage, and authorizing the
; issuance of a building permit for the construction of a single
family home on this property,. is requiring that the agreement for
: the restriction on the number of, bedrooms in any house
constructed on the lot be put on record with the Barnstable
: County Registry of Deeds by recording this document,
3
f
Bk 31014 Pg246 #1447
.NOW, THEREFORE, KATE E. COUET, does- hereby place the
following restriction on her above-referenced land in accordance
: with her agreement with the Town of Barnstable Board of Health,
: which restriction shall run with the land and be binding upon all
successors in title:
1. 225 Osterville West Barnstable Road may have constructed
upon the lot a house containing no more than three . (3)
bedrooms.
KATE E. COUET, agrees that this shall be a permanent deed
restriction affecting 225 Osterville West Barnstable Road,
Osterville, MA, and being shown on the plan recorded in Plan
Book , Page Or on Land Court
Plan
FOR TITLE of KATE E. COUET, see the following deed: BOOK 28622
PAGE 308.
' Or Land Court Certificate of Title Number
: This is intended to correct the Deed Restriction recorded in Book
30980 Page 264 which incorrectly limited the number of bedrooms
to two (2) . The correct number of bedrooms is three (3) .
i
Bk 31014 Pg247 #1447
Execute .as a seal inst ume t this 3rd Day of JANUARY- 2018
Owner' s Sig atur�- KATE E'. COVET
: Owner' s Signature
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss JANUARY 2018
Then personally appeared the above-named KATE E. COUET, known to
me to be the person who executed the foregoing instrument and
: acknowledged the same to be her free act and deed, before me,
f
NOTARY PUBLIC
Rebecca C. Richardson
ygONkaj•. CSC
P 901 O My Commission Expires: 11/23/2018
i�/ mot\111rrr �,r�y;
COMIaO9 1� E,•I
MAssnc�•.•J1
NOTAO Q
SARNSTABLE REGISTRY OF DEEDS
John F. Meade, Register
NOTICE; The Town of Barnstable
recommends that the applicant
seek legal advice to prepare a
properly worded deed
restriction document.
DEED' RESTRICTION
WHEREAS, of
_Vs 'KV 11 w "[tg n e)g o � ))
—T �cff21�I It MA
(address)U U'/�Q
is the owner of
W "lo at d�J � -
2 S r, tI��t � �t°
at 5 (add >
MA (hereinafter referred to as
and being shown on a plan entitled "Subdivision of Land in
MA, Property of
et al, duly recorded in Barnstable County Registry
of
Deeds in Plan Book , Page ;
Or on Land Court Plan Number:
WHEREAS, as the owner of said lot has
(owner's name)
agreed with the_Town of Barnstable Board of Health to a restriction as to the
number of bedrooms which can be included in any home built on said lot as a
pre-condition to obtaining a disposal works construction permit in compliance
with 310 CMR 15,000 State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS, the,Town of Barnstable Board"of Health, as a pre-condition to
granting a disposal works construction permit for a septic system in compliance
with 310 CMR 15.200,. State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing
the issuance of a building;permit for the construction of a single family home on
this property, is requiring that tFie agreement for the restriction on the number of
bedrooms in any house constructed.on the lot be put on record with the
Barnstable County Registry of Deeds by recording this document,
deedr
Bk 30980 Pg265 #65212
NOW, THEREFORE, t,, a ^does hereby place the
(owns s name)
following restriction on his above-referenced land in accordance with his
agreement with the Town of Barnstable Board of Health, which restriction shall
run with the land and be binding upon all successors in title:
1. m5 f tc��Ill(C �� �' � t12YIS bj� 0 may have constructed
(address)
upon the lot a house containing no more than (a) bedrooms,
agrees that this shall be permanent deed
restriction affecting a` Ilacaluct= MA, and
being shown on the plan recorded in Plan Book Paged
Or on Land Court Plan
For title of L4e C . (��_ u ee the following deed: Book Page
- 5C ' . Or Land Court Certificate of Title Number
Executed as a sealed instru t j day of
U n is sig at re
Owner's signature -
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
ss
204
Then personally appeared.the above named
known to me- to be the person"who ekecuted the foregoing instrument and
«�acknowleckged
they awe Xtk a free act and deed, before me,
�g510 N BkA
LU : Notary
?ssncH�.• My commission expires:
(date)
BARNSTABLE REGISTRY OF DEEDS
d=& John F. Meade, Register
0 ,v
TOWN OF BARNSTABLE V
LOCATION le<l, O.f' SEWAGE # �
VILLAGE ASSESSOR'S MAP & LOT/gl�'�e
INSTALLER'S NAME & PHONE NO. 1-7:70--lCgf *,W/
SEPTIC TANK CAPACITY '�-
LEACHING FACILITY:(type) /,�ILX Yd (size)
NO. OF BEDROOMS._ PRIVATE WEL PUBLIC WATE
BUILDER O NER c\ Tz cz(s�t
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED- 5
VARIANCE GRANTED: Yes No
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Commonwealth of Massachusetts
Title 5 Officicit inspection Form
Subsurface Sewage Disposal !'.ystem Form - Not for Voluntary Assessments
225 Osterville/West Barnstable Roa
d
Property Address
William &Ann Monroe
Owner Owner's Name
information is
required for every Osterville r MA 02655 7/1/14
page. CitylTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, t,
use only the tab 1. Inspector:
key to move your t
cursor-do not I
James Ford
e the return Name of Inspector
key.
�Lrab Company Name
P.O. Box 49
Company Address l!
Osterville MA
02655
City/Town State Zip Code
508-862-9400 S12482
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 tide, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furth aluati,on by the Local Approving Authority
7/8/14
Inspe is Signature Date
The y tem 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.
15ins•3113 10M, ection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t .
225 Osterville/West Barnstable Road
Property Address
William &Ann Monroe
Owner Owner's Name
information is
required for every Osterville MA 02655 7/1/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont-),'
F,
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
t .
A) System Passes: ;
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or 11'm310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. fi
Comments: li
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Y
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.
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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 substantjallinfiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tarok 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):
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t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts
Title 5 OfficWAnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�.. ••'`c 225 Osterville/West Barnstable Road
Property Address i!
William &Ann Monroe
Owner Owner's Name
information is ;
required for every Osteryille MA 02655 7/1/14
page. Cityrrown " State Zip Code Date of Inspection
B. Certification (cond . '
❑ 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.. 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(withapproval of Board of Health):
h . .
❑ broken pipe(s);;are,replaced ❑ Y ❑ N ❑ ND (Explain.below):
i,
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
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❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
I.
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❑ 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) arereplaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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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:
Y'
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❑ Cesspool or priv is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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15ins-3/13 i i' Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 3 of 17 .
Commonwealth of Massachusetts
Title 5 Officia Inspection Form
Subsurface Sewage Disposal;;system Form - Not for Voluntary Assessments
A,•'•r 225 Osterville/West Barnstable Road
Property Address ,
William &Ann Monroe
Owner Owner's Name
information is
required for every Osterville MA 02655 7/1/14
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.j' ;
a
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the sytem 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a �6,ptic tank and SAS and the SAS is within 50 feet of a private water
supply well. !
❑ The se t system has a l�c tank and
Y p , SAS and the SAS is less than 100 fee
t but 50 feet or
more from a private water supply well".
Method used to determ:.,ine 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 I
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:
p.
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D) System Failure Criteria Applicable to All Systems:
is
You must indicate"Yes";or:"No"to each of the following for all inspections:
Yes No
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❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Dischdrge or ponding of effluent to the surface of the ground or surface waters
due tb:.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 ''Y2 day flow
ISins•3/13 - !, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
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Commonwealth of Massachusetts
W Title 5 Officialt':,Inspection Form
Subsurface Sewage Disposdf System Form - Not for Voluntary Assessments
t:
C4A. ,"�'" 225 Osterville/West Barnstable'Road
Property Address
William &Ann Monroe t
Owner Owner's Name
information is
required for every Osterville i? MA 02655 7/1/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.j
Yes No
I,
❑ ® Regy�ir{od pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portibn of the SAS, cesspool or privy is below high ground water elevation.
El ® 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.
t
❑ ® 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
m s ste asses if the well water system p analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of annmonia 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
criteriq::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.
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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 mustindicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
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Yes No -
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❑ ❑ the s'yste'm 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
Areai'-`)W- PA) or a mapped Zone II of a-public water supply well
f.
If you have answered "yesj'to any question in Section E the system is considered a significant threat,
or answered "yes" in Section., above the large system has failed. The owner or operator of any large
system considered a signifiicant threat under Section E or failed under Section D shall upgrade the
system in accordance with110 CMR 15.304. The system owner should contact the appropriate
regional office of the Depatment.
t5ins-3/13 �; Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
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Commonwealth of Massachusetts
V Title 5 Officia . Inspection Form
Subsurface Sewage Disposaf,System Form -Not for Voluntary Assessments
225 Osterville/West Barnstable Road
Property Address
William &Ann Monroe
Owner Owner's Name
isrequired for every Osteryille MA 02655 7/1/14
page. CitylTown State Zip Code .Date of Inspection
C. Checklist `
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Check if the following have',!been done. You must indicate"yes" or"no" as to each of the following:
h .
Yes No
® ❑ Pumpin"information was provided by the owner, occupant, or Board of Health
❑ ® Were arty of the system components pumped out in the previous two weeks?
l:
® ❑ Has thesystem 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 ins!'iection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
availatile.note as N/A)
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?
fl y
® ❑ 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,
dimensi66s, depth of liquid, depth of sludge and depth of scum?
El ® 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:
i..
® ❑ Existintg',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
approxlirnation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information'
Residential Flow Conditions:
3
3
Number of bedrooms(design):; Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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15ins•3113 `. i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official-Inspection Form
Subsurface Sewage Disposal:System Form - Not for Voluntary Assessments
I'F'
„a 225 Osterville/West Barnstabld Road
Property Address
William &Ann Monroe ¢'l;
Owner Owner's Name
information is '
required for every Osterville F MA 02655 7/1/14
page. Cityrrown ; State Zip Code Date of Inspection
D. System Informatioli�:'
Description:
�i
Number of current residents:;- ; 1
Does residence have a garbage grinder? ❑ Yes ® No
i, ;
Is laundry on a separate se'vyage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected?- :: ❑ Yes ® No
Yt '
Seasonal use? El Yes ® No
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Water meter readings, if available (last 2 years usage (gpd)):
Detail:
4
unavailable
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Sump pump?
❑ Yes ® No
1. current)
Last date of occupancy: y
f Date
Commercial/Industrial Fldwi Conditions:
Type of Establishment: r
Design flow(based on 310.'CMR 15.203): Gallons per day(gpd)
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Basis of design flow(seats/'persons/sq.ft., etc.):
Grease trap present? El Yes ❑ No
Industrial waste holding tank present? El Yes ❑ No
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Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No
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Water meter readings, if a4lable:
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 17
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Commonwealth of Massachusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposa(i,Gystem Form - Not for Voluntary Assessments
e 225 Osterville/W
a est Barnstable:Road
Property Address
William &Ann Monroe
Owner Owner's Name
information is
required for every Osterville MA 02655 7/1/14
page. CltylTown State Zip Code Date of Inspection
D. System Informatign (cont.)
Last date of occupancy/use.+`.
Date
Other(describe below):
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p
+'. General Information
Pumping Records:
f ' •
Source of information: pumped within a year
Was system pumped as part of the inspection? ❑ Yes ® No
i
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 ce>sp'ool
❑ Privy f
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
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❑ 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
t,
❑ Tight tank.F%ttach a copy of the DEP approval.
❑ Other(describe):
t5ins•3,,I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
u Title 5 Official :Inspection Form
Subsurface Sewage Disposali`System Form - Not for Voluntary Assessments
i'
e,•'" 225 Osterville/West Barnstablef Road
Property Address
William &Ann Monroe
Owner Owner's Name
information is i..l .t
required for every Osterville MA 02655 7/1/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all compo;rtents, date installed (if known)and source of information:
installed on 5/24/1995 E;
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Were sewage odors detectedwhen arriving at the site? ❑ Yes ® No
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Building Sewer(locate on site plan):
Depth below grade:
P 9 feet
t -
Material of construction:-
❑ cast iron ® 40;F VC ❑ other(explain):
Distance from private water;supply well or suction line:
feet
Comments (on condition ofjoints, venting, evidence of leakage,etc.):
Septic Tank (locate on site;plan):
18"
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: 1500 gal.
Sludge depth: :i :' 2
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!Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
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Commonwealth of Massachusetts
Title 5 Offi
ciailminspection Form
Subsurface Sewage Disposal;System Form - Not for Volun
tary Assessments
a
225 Osterville/West Barnstable Road
Property Address ',i a
William &Ann Monroe
Owner Owner's Name
information is
required for every Osterville MA 02655 7/1/14
page. City/Town D. System State Zip Code Date of Inspection
Informatior ;(cont.)
Septic Tank (cont.) K
A'
Distance from top of sludge�ta bottom of outlet tee or baffle 29
Scum thickness I 1"
Distance from top of scum to fop of outlet tee or baffle 6
Distance from bottom of scum.to bottom of outlet tee or baffle 14
How were dimensions determined? measure
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 liquid level was even with the outlet invert There was no sign of leakage. '
Y
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Grease Trap (locate on site plan):
Depth below grade: .
x
feet
Material of construction:
,i
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
F:
Distance from top of scum to top of outlet tee or baffle
is
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last um In
P P� 9:
Date
15ins•3/13 I� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
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Commonwealth of Massachusetts
Title 5 Official, inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
A,Asye'_ 225 Osterville/West Barnstable Road
Property Address
William &Ann Monroe
Owner Owner's Name
information is required for every Osterville ; MA 02655 7/1/14
page. City/Town State Zip Code Date of Inspection
D. System Informatiokh (cont.)
l
A.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet';invert, evidence of leakage, etc.):
t,
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):
s
N/a
Dimensions:
Capacity:
' gallons
Design Flow:
i gallons per day
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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.):
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*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
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Commonwealth of Massachusetts
Title 5 Official,; Inspection Form
Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments_
225 Osterville/West Barnstable!Raad
Property Address �!
William &Ann Monroe
Owner Owner's Name
information is required for every Osterville MA 02655 7/1/14
page. City/Town Fi State Zip Code Date of Inspection
D. System Informatio (cont.)
.i
Distribution Box(if present'jmust be opened) (locate on site plan):
Depth of liquid level above outlet invert even
Comments (note if box is leve[.and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or,out.of box, etc.):
The box was normal. The cover was 40" below
i
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Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: i;: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
t.. .
i .
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y
i !
* 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):
y- :
If SAS not located, explain why:
1
i y ,
1 .
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
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I
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 225 Osterville/West Barnstable Road
Property Address
William &Ann Monroe '
Owner Owner's Name
information is
required for every Osterville MA 02655 7/1/14
page. City/Town State Zip Code
p" Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits! number:.
❑ leaching cha'rbers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 12'x 40'
❑ 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.):
The field was clean. There was no sign of failure. A camera was used
ti
I
Cesspools (cesspool must bepumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
f;
Depth of solids layer I
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
(Sins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
l'
Ili
I �I
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal`System Form Not for Voluntary Assessments
I
225 Osterville/West BarnstableiRoad
Property Address
William &Ann Monroe
Owner Owner's Name i
information is required for every Osterville ?' + MA 02655 7/1/14
page. City/Town State Zip Code Date of Inspection
D. System Information`(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): I'
i
r,.
Privy(locate on site plan): ;'
i
Materials of construction: f;
Dimensions
i •
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): r;
N/a r
4.
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l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 OfficiAl('Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M a,•y'•y 225 Osterville/West Barnstable iRoad.
Property Address
William &Ann Monroe
Owner Owner's Name
information is
required for every Osterville ,+ MA 02655 7/1/14
page. City/Town e
t, State Zip Code Date of Inspection
D. System Information'(Copt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
,
® hand-sketch in the area below
❑ drawing attached separately
OUR
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t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
, e
achusetts
Commonwealth of Mass
Title 5 Official ,Inspection Form
Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments
I�
��•. ,•`'�r 225 Osterville/West Barnstable;Road
Property Address
William &Ann Monroe '
Owner Owner's Name i
information is
required for every Osterville MA 02655 7/1/14
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: ':
❑ Check Slope
❑ Surface water i
❑ Check cellar
❑ Shallow wells
l +/-Estimated depth to high gro6nd water: 30'
feet
Please indicate all methodssused to determine the high ground water elevation:
e,
❑ Obtained from system design plans on record
If checked, datd of design plan reviewed:
Date
W
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Using topo and water contours maps
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed UWS;database -explain:
I,
You must describe how youlestablished the high ground water elevation:
see above
• .
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
f:
t5ins•3/13 "• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I a
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments
•''t 225 Osterville/West Barnstable Road
Property Address
William &Ann Monroe '{
Owner Owner's Name
information is
required for every Osteryille MA 02655 7/1/14
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— E'stimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins-3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT'(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works '
construction permit signed by me dated 22 concerning the
.�• property located at Zz cxic- ra" meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
h
• There are no private wells within 150 feet of the proposed septic system
A j
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : c*r— -A S� u,--�. DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
A
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Bi-ti.pnittl Workii Tomitrnrtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair (_) an Individual Sewage Disposal
System at:
- -------!.....- ------ s -------------------------------------------------- -----------------------
L cation-Address or Lot No.
G .............
... ..... X_1.. Q ------•-----------•----- .................................................................................................
/�,,C,sOwner r�� �����L y Address
�..........S�LTN�V ..........do------•-----------a!�...... 140- 1 v4 -------�!i .........
Installer Address
UType of Building Size Lot.........................:.Sq. feet
.� Dwelling— No. of Bedrooms Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ---------------------------- No. of persons.-_-_-----_----__-__-__._.- Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------- ---------------------------- ------
lz��_----------------------•-------
w Design Flow--------------------------------------------gallons per person per day. Total daily flow......__....__......................,......gallons.
WSeptic Tank—Liquid capacitv-----__--_-gallons Length---------- ___----- Width --_...._----_ Diameter................ Depth................
x Disposal Trench--No. .................... Width-------------------- Total Length.................... Total leaching area_------_.-__-----_-sq. ft.
Seepage Pit No--------------------- Diameter-------------....... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolatibn Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-._---._.--.---_---_-...
fit Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water...--_--------------_-_.
x Description of Soil �'�-----�-- ---------------------•---------------------------------------------------
---.
O ------ ----- ------------- ------...---------
U �---- ..:-----------------N -------�°�' ----------------------------------------------------------- ---------------------.....----------------------------...-----------------
w
UNature of Repairs or Alterations—Answer when applicable-AV.-4 zt�. l p...... 0_0.�
-------------------------•---------•----
Agreement-.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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.
Signed ....... ---- Zz1 4J.
Application,Approved BY -------- - ------------------=----------------- ------------------------ --------Z ...
._................_.................................._., Dace....
Application.Disapproved for the following reasons- -------------------_...........-------------------------------------------------------------------------------------------------`-
------------ire-----------------
PermitNo- ------------------------------------------------------------------- Issued ........... -- .. ........._... .. .......
Date
1
f` ^Fsa ....
THE COMMONWEALTH OF MASSACHUSETTS"
BOAR® OF HEALTH
PTOWN OF BARNSTABLE
A## rtttioaa for Diopooal Uludw Towitrurthinp ranit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
• System at:
L cation-Address 1 or Lot No.
t
........... .. --•------------•-- ..................................................................................................---------------------------------•--.....-•------------•------•----....----------.._..----......-.
Owner
Address
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms-_ ------------------------------Expansion Attic ( ) Garbage Grinder (114)
aOther—Type of Building ____________________________ No. of persons--------_------------------- Showers ( ) — Cafeteria ( )
dOther 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.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-- '----------------------------------------------------•-------•-....... Date........................................
Test Pit •.No. 1................minutes per inch Depth of Test Pit._____-_---__-____._ Depth to ground water------------------------
44 Test Pit No. 2................minutes per inchi Depth of Test Pit-------------------- Depth to ground water........................
P' --•--------------------------------•.........................................................................................................................O Description of Soil....0-1-._.._QU71,
��------------------••-------------------------------------------------------------------------------------------------..-----_•-----
U ----------•------------------------------------------------------------------•--••---•-•-----------------.
-------------------------------------------------------------------------------- ......................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable_&v'�-4____'E-_:.GAI------1�.... xt +(± •..... ads
..
Agreement: .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—*The undersg ed further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
ZSign —
ed— -....... ........................... ............ ....... .. se�`t?--.
------
.
Application.Approved By�- .---/l�----------------------------------------------------------- j � �. .....
s.......
..... .. ....
Date
Application`Disapproved for the following reasonr: ---------------------_........_.............. ... ................ . ......... ..................
-------------- ------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ........................................
Date
PermitNo- ---------------------------------- -------- ------------------ Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tex#ifi ate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired'( )
by .......... -«-' -----------��s�-e'....................--------------I ... ..- ------------------....-------------------------------.-------------
--------- Installer
at ----------22-- - SST-----t.J S ------- -�---
� ---------------�.- -----_----------------------------------------------
has been installed in accordance with the provisions of TITLE 55 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .....:7...�J..� _ ..7..-- dated -----Of ,.,/-2.Z...` �.-�_..._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... . ....tire-J--- -------- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No..................... FEE ........
%poloa1 Workii Tuntrudion 11amit
Permission is hereby granted...... ......P®S7
to Construct ( ) or Repair an Individual Sewage Disposal System
Street /
as shown on the application for Disposal Works Construction Permit No51✓37 Dated.._.___ /_2_ ,.�-�.......
�==..
- -• � � ��� Board of Health
DATE.. ` ((( ....... .......
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
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SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM
Address of property AA-J ®WV'. e .` v�. 9.��2VA
owner's name 0-o�v-ov
Date of Inspection
-/6L y- 1
PART A n��
CHECKLIST
Check if the following have been done:
Pumping -information was requested of. the owner, occupant, and Board of
Health.
None of the system components have been pumped '.for at least two weeks "
and the system has°, een receiving normal .fl'ow, rates during that
period. Large volumes of water have not been introduced into the
system recernt lyor as' part' of^ this inspection. '.
As built plans have been obtained and examined. Note if they are- not
available with N/A.
The facility. or dwelling was _inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system 'components, excluding the SAS, , have been located on the
site.
yC The septic tank manholes were uncovered, opened, and the- interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
?� The size and =location of the SAS on the site has been determined`.based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper .maintenance of SSDS.
K
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8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLAW CONDITIONS
If residential
number of bedrooms
number of current resident
garbage grinder, yes or Q
o-
laundry connected to sy _ m:,�or no
seasonal use, yes o no
If nonresidential , calculated flow:
w ter meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping reco� and source of information:
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Typ of system
Septic tank/distribut on absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes attach previous inspection
records, if any) '
Other (explain)
Approximate age of all components. Date installed, if known.' S.ource of
information:
N �a�
Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
i�
depth below grade: LO
.
material of construction: concrete metal FRP other(explain)
dimensions: lift -S�Pjlc' r�
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
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, recommendations for repairs, etc. )
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate. on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leac
eaching fields, number, . dimeIs
nsions _ g/
rflow cesspo 21
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
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
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.')
PRIVY:RI Y.
(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, recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE 1' SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate al wells within 100 ,
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csv
6<< � A.
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
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12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
YlDischarge or ponding of effluent to the surface of the ground or
surface waters?
t:
4Z Static liquid level in the distribution box above outlet invert?
r,A Liquid depth in cesspool <6" below invert or available volume<flow? 1/2 day
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration?. tank failure imminent?
Is any portion of the SAS, cesspool or privy:
_ below the high groundwater elevation?
within 50 feet of a surface water?
(are within 100 feet of a surface water supply or tributary to a surface
Nv water supply?
within a Zone I. of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply 1 well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysis
, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
F�,i,�.,
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IC,KEY y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1,
CERTIFICATION
Name df Inspector: Donald Perkins
COMPEIrlY Name: Hickey Construction Company, 36c `
Comp,ahy `Address: 38 Rosery Lane, Hyannis, MA. Q 601
1
teL::� (508) '771-41-28
Property :addreut. r
Fl
'` C•_•,-,�ti cation Statement : " 1
I certify that I have 'personally inspected the sewage
system at this address and that the information reported is p
accurate and complete as of the time of inspection:.° .The
' �Hspection was performed .and any recommendations reqardin9 ' . '
t .
upgrade, maintenance, and repair are consistent with my training
.`and experience in the proper 'Function and maintenance of on-ii.te "
sewage disposal systems. t Oil
-
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,
F Check'} ne: `.
d
„ r I have not found any information which i,ndicat:.es that
the system fails to adequately. protect pubI10 health
or the environment as defined in 310 CMR :15:30 Any
failure criteria not evaluated are stated 'in. the
"' J FAILURE CRITERIA section of this form.
5d n
} - ! ' IN
I have determined that "the 'system fails s" de ined� u �`,
310 CMR 15. 303: The basis for this deter inatr3on is J �,���
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provided in the FAILURE CRITERIA section of tht farm yyr'
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signature:.--.
` Inspector' s �
�1 'Date:
,
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to -e -� t t
hi.g n� sv3tem owner: C.��-(��
1 1 i M1
�,Wyei Cif applicable) ;{,,�• s�;
t �:pproving authority
at:
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38 Rosary Lane • Hyannis, MA 02601 �508 ,771 4 8�- a
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I MF
DATA
Sun2rior Home Builders & Insoectors.
ASSESSORS MAP N0: / 9 I p o. Boy, 544
v
i . Carver , MA 02330
PARCEL NOL. 0 4F�?,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 6?9,_ 66_Ierv, Ile W. 64m skb1c
Owner' s name
Date of Inspection [i/�%r
7 PART A APR 2 0 1995
CHECKLIST H THDEP'T•,
Check if the following have been done:
�Ja Pumping information was requested of the owner, occupant, and Board of
Health. i ^
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or' .as part of this inspection.
As built/ plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
- > The site was inspected for signs of breakout.
r
A11 system components, excluding the SAS, have been located on the
site .
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and .occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
=3 number of bedrooms
L_ number of current residents
garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
l
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
System pumped as part of inspection, es o
if yes, volume pumped Y r no
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
cesspool
y
Overflow cesspool
Privy,
t---- Shared system (yes or no) (if Yes, attach ins
records, if any) previous
Other (explain) inspection
Approximate age of all components. Date installed if
information: known.
Source of
------------
Sewage odors detected when
arriving at the site, yes or no
I,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
XLZ Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
/✓oa �� Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 da,
flow?
_ �� GCS S,./'�'°'�-:� ,/rii L[, s'�n� �-'�' /�:�f�-� _ 7T_o..,•
C
Required pumping 4 times or more in the last year?
number of times pumped --,_/ c �
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
M•�C below the high groundwater elevation?
wo within 50 feet of a surface water?
/tv within 100 feet of a surface water supply or tributary to a surface
water supply?
within a zone I of a public well?
tic' within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, Dot the SAS) ?
within 50 feet of a private water supply well?
�d less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water anal} 1
.for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS)
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching., fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendatio
ns ons for maintenance or repairs,etc. )
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert 1 , < < : ,. ,.. ., ,-�, z".,1 ,
depth of solids layer 1
depth of scum layer 1<
dimensions of cesspool
materials of construction �,; ;Z ,, � „ ���. 2 , .7„ ,�,�_� }7Cf
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments: 1
(note condition of soil , signs of hydraulic. failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
I
II �
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Company Name
Company Address
Certification Statement
I• certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as ,of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maiitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
�T �
FAILURE CRITERIA section of this form.
ve determined that the system fails to protect public health and
the- environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature ill
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
t
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
D.S`t L•et!=LU 4t-) , I.SX .i77i-7/1 LC ��. C/��i T -/` LLL' /i414 S s
Z
Div L-/lw yp%''
E 944
DEPTH TO GROUNDWATER
•7 depth to groundwater
l
meth94 of determination or approximation: