HomeMy WebLinkAbout0130 PARKER ROAD UNIT BLDG 2 UNIT 2 - Health 130 Parker Road
Osterville P, = i
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Commonwealth of Massachusetts D357f 066
Title 5 Official Inspection Formt
Subsurface Sewage Disposal System Form Not for VoI unta Assessments
v 130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
x;
Owner Owner's Name
Information is required for every Osterville MA 02656 11-26-18
page. Chy/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. Inspector Information
fdlingoutfom,s 64
on the computer, 1�
use only the tab James D.Sears
key to move your Name of Inspector
cursor-do not Capewide Enterprises
use the return Company Name
key.
153 Commercial Street
Company Address
Mashpee MA 02649
Cityffow State Zip Code
nay 508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP-approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15,000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true,accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2, ❑ Conditionally Passes
3, ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
12-5-18
I tor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this Inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original form should be sent to the system owner and copies sent to
the buyer, if applicable,and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
r in the future under the same or different conditions of use.
t5inap.doc rev.V26 018 Title 5 Oftal Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
Information Is required for every Osterville MA 02656 11-26-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any fallure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below);
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
,.' 130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-18
page, Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below);
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below);
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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TN, Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
<I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road ParkerPlace
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-18
page. Cilyfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, If any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other,
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
01-1 P
130 Parker Road (ParkerPlace)
Property Address
First Property Maint
Owner Owner's Name
information is psterville MA 02656 11-26-18
pagre. for every City/Town
State Zip Code Date of Inspection
C. Inspection summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet Invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in me�i is less than 6" below invert or available volume is less
than day flow 2-FA e141"0
® 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.
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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal colifonm 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 2000 gpd-
10,000 gpd.
El ® The system fails. t 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.
5) 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 C.4.
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 I I of a public water supply well
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Commonwealth of Massachusetts
ivTitle 5 Official Inspection Form
ry
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint
Owner Owner's Name
information is Osterville MA 02656 11-26-18
required for every
u F
per. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if different from owner)provided with
❑ ® information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)(310 CMR 15.302(5)1
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road ParkerPlace
Property Address
First Property Maint
Owner Owner's Name
information is Osterville MA 02656 11-26-18
required for every page. Y Cit !Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 9 Number of bedrooms(actual): 9
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 990
Description:
2000 Gal. Tank D Box and leaching field.
NA
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings,if available(fast 2 years usage(gpd)): 2016-50,000GaIs2017-52,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
Wnsp.doc rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road(ParkerPlace)
v Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-18
per. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
2. Comm ercial/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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancyluse: Date
Other(describe below):
3. Pumping Records:
Source of information: 13/14115
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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li
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
130 Parker Road (ParkerPiace)
Property Address
First Property Maint
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-18
page. City/Tom State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes,attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
malntenance contract(to be obtained from system owner)and a copy of latest
inspection of the IIA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information;
2000 Permit# 2000-085.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
38"
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.):
Pipeing is 4" PVC SCH -40 -
I
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint
Owner Owner's Name
requir required for
Osterville MA 02656 11-26-18
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cunt,)
6_ Septic Tank(locate on site plan):
r 30"
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
2000 Gal. Precast H-10
Dimensions:
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
3'-1"
0"
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
2'
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level.Tank at 30" below grade w/outlet cover at 7'. Outlet tee. No sign of leak age
or over loading
t5inap.doc•rev.7l2612018 Title 5 Official Inspadon Form;Subsurface Sewage Disposal System•Page 1D of 18
pt a5ed xeJ dH ££:80 860Z 90 D80
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Cisterville MA 02656 11-26-18
per. Clty(Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
` I
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
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66 a5ed xeJ dH ££:80 860E 90 Oa0
Commonwealth of Massachusetts
�95 Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
Information is required for every Osterville MA 02656 11-26-18
Page City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D Box is 16"x21"-42"below grade. Box is clean and solid w/five lines out. No sign of over loading or
carry over.
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
�t) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
required
re Cisterville MA 02656 11-26-18
required for every
page. City town State Zip Code Date of Inspection
D. System Information (cost.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
` If pumps or alarms are not in working order,system is a conditional pass.
11. Soll Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number,dimensions:
44'x31"
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
t5insp.doc•rev.MOM Tille 5 Offwial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
£� abed xe� dH ££:80 8 i3OZ 90 DaG
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-16
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Leaching is a five pipe field 44'x31'. Ck D Box- Camera out line's and prob. No sign of over loading
or solid carry over. No sign of holding water.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
M
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
..Vw1l 130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every OsteryiIle MA 02656 11-26-18
page. cityrrown State Zip Code Date of Inspection
D. System Informatlon (cont.)
13. 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.):
I
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t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-18
pa", CityfTown State Zip Code Date of Inspection
D. System Information (cons.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters
the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
15insp.doc•rev.7/26/2018 Tine 5Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
g 6 abed Xed dH V£:80 9 602 90 �80
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02656 11-26-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
ND
Estimated depth t high ground water: 101+
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:
Auger Hole 10'no G.W.Auger T.H. hole 5'+. Below bottom of field.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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4, Commonwealth of Massachusetts
IVTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (ParkerPlace)
Property Address
First Property Maint
Owner Owner's Name
information Is Osterville MA 02656 11-26-18
required for every
page, City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section,
® B. Certification: Signed&Dated and 1, 2, 3,or 4 checked
® C. Inspection Summary:
1;2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5inep.doc•rev.7/213 018 Tltle 5 Official Inspection Form.Subsurface Se"o Disposal System Page 18 of 18
86 a5ed xej dH 5E:80 860E 90 DaO
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dlaposaf Syebsm Forth-Not for Voluntary Asse63mwts
130 Parker Road Marker Place)
Property Addt a
FirsLftperty Maint.
Owner Ownerb Name
IMamatlon is
Mquiped for every OsWyile MA 02655
one. Gwo"n Stale Z!p Code Date atInepcalon
D. System Information (cont.)
Sketch Of Sewage Disposal System: pmvlde a view of the Sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all weft within 100 feet.Locate
where public water supply enters the bulkling.Check one of the boxes below-
hand-sketch in 1he area below
_ ❑ drawing attached separately
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Commonwealth of Massachusetts 1P-o3r
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i°
° 130 Parker Road (Parker Place) '
M
Property Address
First Property Maint.
Owner Owner's Name
information is
required for every osterville MA 02655 12-1-15
page. City/Town State Zip Code Date of Inspection;,'
l''�_E
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 / y
filling out forms / # l 1�G/
on the computer, I OF A4,q
use only the tab 1. Inspector:
key to move your Cj '••SG
cursor-do not James D.Sears JAM ES :m
use the return Name of Inspector _ ;�„_
key. * '• Cl-
CompanyO •'
p Na Enterprises, LLC
Name
153 Commercial Street %F im-1..
��'' ..110OAA ``�����
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
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
12-5-15
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
�0
t5ins•3/13 Title 5 Official Ins ection Form:Subsurface Sewage Disposal System••2-41-fi�lP 9 P Y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 2000 Gal. Tank D Box and leaching field.
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
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. Cityrrown 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. CityTTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in 4wapW is less than 6" below invert or available volume is less
than '/day flow X EAfIlI 16
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
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 other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l ��M 130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
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?
® ❑ 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): 9 Number of bedrooms (actual): 9
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 990
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 2000 Gal. Tank D Box and leaching field.
Number of current residents: NA
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. Cityrrown 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: 13/14/15
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
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
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:
2000 Permit # 2000 -085.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 38°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.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 30"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:
2000Gal. Precast H-10
1
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Parker Road Parker Place
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. Cityfrown 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
3'-1"
0"
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
2'
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 30" below grade w/outlet cover at 7". Outlet tee. No sign of leak
age or over loading.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Rd Parker Place�M Road )
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D Box is 16"X 21"-42" below grade. Box is clean and solid w/five lines out. No sign of over loading
or carry over.
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:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Road Parker 130 R a (Parker Place
)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
44'x31'
❑ 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.):
Leaching is a five pipe field 44'x31'. CK D Box-Camera out line's and prob. No sign of over
loading or solid carry over. No sign of holding water.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is
required for every Osterville MA 02655 12-1-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. City/Town State Zip Code Date of Inspection
D. System Information
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
P
7 ^6 / fir d 1
IYtRiGl� S
t5ins-3113 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
°,M s 130 Parker Road (Parker Place)
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
ND 10'+
Estimated depth to high ground water: 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:
Auger Hole 10' no G.W. Auger T.H. hole 5'+. Below bottom of field.
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
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�G
130 Parker Road (Parker PI,Mace
Property Address
First Property Maint.
Owner Owner's Name
information is required for every Osterville MA 02655 12-1-15
page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
s Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Mgmt
Owner Owner's Name
information is ill t Oserve Ma 02655 11-29-12 required for every
page. City/Town State Zip Code Date of Inspection -'
Inspection results must be submitted on this form. Inspection forms may not be altered in an
p Y Y
way.Please see completeness checklist at the end of the form.
ImPOftant:When A. General Information
filling out forms ���aattrur4Hn���
on the computer, ..OF Mq
use only the tab 1. Inspector: :N 41 .. ss9�
key to move your ox •• • ''•yG
cursor-do not JAMES
James DSears' = .m
use the return Name of Inspector Co .
key.
Capewide Enterprises,LLC_ o o
Company Name �i, 4. I�r�`S='U
153 Commercial St '' +lN SpG�``\`��
Company Address
Mashpee Ma 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certificatio
n •
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 16.340 of
Title 5(310 CMR 15.000).The system:
® Passes n Conditionally Passes w ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority -
,a --4
•11-29-12
ctor's Signature Date s �
The system inspector shall submit a copy of this inspection report to the Approvl(tg Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is alshared system�Rrl
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. r
-_
""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.
� I
t5ins•11/10 Title 5 Official Inspection �S bsurrace Sewage Disposal Sy am•Page 1 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Mgmt
Owner Owner's Name
information is Osteryille Ma 02655 11-29-12 required for every "
page. Cityrrown 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:
® 1 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 isless than-20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 2 of 17
x ,
}
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First.Property Mgmt
Owner Owner's Name
information is Osterville Ma 02655 11-29-12 required for every '
page. Cityrrown State Zip Code Date of Inspection
i 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 ❑,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 1 e s . The
Y q p p 9 Y PP O
system will pass inspection if(with approval of the Board of Health):
❑ broken.pipe(s)are replaced ;❑ �Y ❑ N ❑ ND(Explain below):
w .
❑ 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
❑ a Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh
t5ins•11/10 Title 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First.Property.Mgmt
Owner Owner's Name
information is Osterville Ma. ' 02655 11-29-12
required for every - '
page. Citylrown 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 li water
Y p a pubs ate
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 cesspoolEl "
. 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in ewiapeN is less than 6" below invert or available volume is less
than Y2 day flow A F.4 c1lo Al G'
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place )
Property Address
First Property Mgmt
Owner Owner's Name
information is
Osterville Ma -
required for every 02655 11-29 12
page. CityfTown 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.
❑ , Z 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
en and nitrate nitrogen is equal to or less tha
n 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the-
questions in Section D.
Yes No {.
❑ ❑ the system is within 400 feet'of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
1f 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•11/10 Title 5 Official insp
ection Form:Subsurface Sewage Disposal System.•Pape 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t
130 Parker Road (Parker Place) °
Property Address
First.Property Mgmt
Owner Owner's Name .
information is Osterville Ma 02655 11-29-12 required for every f
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:
t
Yes No `
® ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ ,` Was the facility or dwelling inspected for signs of sewage'back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth.of sludge and depthof.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:
0 ❑ 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 r
Residential Flow Conditions:
R Number of bedrooms(design): 9 Number of bedrooms(actual): 9
' DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x'#of bedrooms): 990
15ins•11/10 , Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property.Mgmt
Owner Owner's Name
information is required for every Osterville Ma 02655 11 29-12
page. City/Town State Zip Code Date of inspection
D. System Information
Description:
The-system is-a 2000 gallon tank,D Box and laeching Field
Number of current residents: o
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
Seasonal use? ® Yes ❑ No
Water meter.readin s,if available last 2 ears usage d na
9 ( Y 9 (gp ))=
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: na
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gauons 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•1111.0 Idle 5 Official Inspection Forth: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
y � 130 Parker Road (Parker Place) .
Property Address , ..
.First Property Mgmt
Owner owner's Name
information is required for every Osterville Ma 02655 11-29-12
page. CityfTown State Zip Code Date of Inspection
D. System Information. (cunt.)
Last date of occupancy/user Date
Other(describe below):
General Information
Pumping Records:
Source of information: 09/10/11/12
Was system pumped as part.of the inspection? ❑ Yes ® • No
If yes,volume primped: gallons
How was quantity pumped determined? F
Reason for pumping: g
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool -
❑ Overflow cesspool
❑ Privy A
❑ Shared system es or no If es,attach previous ins action records, if an Y (Y ) C Y P p Y)
❑ 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 1/A system by system operator under contract j
❑. Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins"11110 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Mgmt
Owner owner's Name
information is p terville Ma 02655 11-29-12 required for every � "
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:
2000 permit#2000-085
Were sewage odors detected when arriving at the site? ' ❑ Yes ® No r
Building Sewer(locate on site plan):
Depth below grade: r feet
ti
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.):
Pipeing is 4"PVC SCH 40 "
Septic Tank(locate on site plan): y
Depth below grade: tee"
Material of construction: T
®concrete ❑ metal ❑fiberglass ❑.polyethylene ❑other(explain)
- If tank is metal, list age:
r years
4 Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ElNo
Dimensions: 2000 Gallon Precast
1„ ;
Sludge depth:
mns•11/10 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
130 Parker Road (Parker Place)
Property Address
'First.Property Mgmt,
Owner owner's Name
information s Osterville Ma' 02655 11-29-12
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
3'-1"
a 0
Scum thickness
.. 8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
2'
How were dimensions determined? Asbult Tape Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level w/out let tee Tank at 30"below grade w/outlet cover at T' .No sign of leakage
or over loading
a F
Grease Trap(locate,on site,plan):
Depth below grade: w feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene. ❑other(explain):
Dimensions: ,
Scum thickness t
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 ins
pection Forth:Subsurface Sewage Disposal System•Page 10 of 17 ,
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First.Property Mgmt
Owner owner's Name
information is Osterville Ma 02655 11-29-12
required for every
page. CitylTown 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 constru
ction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
• gallons
Design Flow gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: y ❑ Yes, ❑ 'No
Date of last pumping: r 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 ins
pection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First.Property.Mgmt
Owner Owner's Name
information is required for every Osterville Ma 02655 11-29-12
page. Citylrown. State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D Box is 16"x21"42"below grade w/5 lines out.Box is clean and solid, no sign of overloading or
solid carry over
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 net located, explain why:
t5ins•11/10 Tine 5 Official Inspection Forth:Subsurface Sewage Disposaf System•Page 12 of 17
Commonwealth of Massachusetts 4 -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "
130 Parker Road (Parker Place)
Property Address
First Properly Mgmt
Owner Owner's Name
information is required for every Osterville Ma 02655 11-29-12
_
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.).
Type:
❑ leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number, length:
® Teaching fields number, dimensions: 44'x31'
❑ 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.):
Leaching is a Five pipe field 44'x3.1'. Camera out lines probe and auger hole at field. no sign of over
loading or holding water
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 ,
g
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins 11110 Title 5 Official inspection Fonre Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Parker Road (Parker Place )
Property Address
First Property Mgmt
Owner Owner's Name
information is required for every Osterville Ma 02655, 11-29-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan): ,
Materials of construction;
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,
etc.):
{
P
t5ins-11110 , Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
f r 9
M R
:F
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 130 Parker Road (Parker Place)
Property Address
First Property Mgmt
Owner Owner's Name
information is required for every Osterville Ma 02655 .11-29-12
page. Citylrown State Zip Code Date of inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent.reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below '
0 drawing attached separately
-R.-/ _ 3
a
� . Polk
_ s
i5ins•11110 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 15 of 17
P.
Commonwealth of Massachusetts
uJ'
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Mgmt
Owner Owners Name
information is required for every Osterville Ma 02655 11-29-12-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: `
❑ -Check Slope-
0 Surface water
❑ Check cellar
❑ Shallow wells `
Estimated'depth to high ground water: 10'+
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(abu ting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
❑ fAccessed USGS database-explain:
You must describe how you established the high ground water elevation: _
Auger Hole 10'no ground water Auger Hole 5'+below bottom of field.
h
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
of US
ill Inspedflah r p6dion Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
130 Parker Road (Parker Place)
Property Address
First Property Mgmt
Owner Owner's Name
information is Osterville Ma 02655 11-29-12
required for every .
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
n r. M•4.
t5ins-11110 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17