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HomeMy WebLinkAbout0234 PARKER ROAD UNIT BLDG 1 UNIT 1A - Health 234 Parker Road b , , " • " n q 4 e c .. y I m , I , r& p � , I ` Commonwealth of Massachusetts II(P—Olo I - 00 A :. 12P Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address r Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms S) on the computer, 1 w use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return Company Name key. p y P.O. Box 49 Company Address Osterville MA 02655 Cityrrown State Zip Code � 508-862-9400 S12482 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 i 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 Ev uation by the Local Approving Authority 4. ❑ Fails 5/24/2021 Inspec 's Signature Date The ys m inspector shall submit a copy of this inspection report to the Approving Authority (Board of He 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 i conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form !o� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road V� Property Address Aunt Temples Condo's building#1 A&B&E, 3 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating-that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts �a N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's .building#1 A&B&E, 3 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 y Commonwealth of Massachusetts s Title 5 Official Inspection Form �} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �r 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is Osterville required for every MA 02655 4/26/2021 page. CItyrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Insp ection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condos building#1 A&B&E, 3 units Owner Owners Name information is OSterville required for every MA 02655 4/26/2021 page. 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis i and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form Not for Voluntary Assessments J� 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E 3 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �- S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's buildin #1 AME, 3 units Owner Owners Name information is required for every Osteryille MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: system is 3- 1 bedroom units Number of c unknown 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^ � 234 Parker Road Property Address Aunt Tempies Condo's .building#1 A&B&E 3 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped yearly for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I Commonwealth of Massachusetts ,A Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road u Property Address Aunt Tempies Condo's buildinq#1 A&B&E, 3 units Owner Owners Name information is required for every OSterVllle MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ' ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed on 11/4/2001 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): r , t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is required for every Osteryille MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 28"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y El 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: 2 Distance from top of sludge to bottom of outlet tee or baffle 25 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 12 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 Tees were present. There was no sign of leakage. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's buildin #1 A&B&E, 3 units Owner Owners Name required for is every Osteryille required for eve MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet 4 Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a 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): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts o Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments * !% 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *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 Even 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.): The D-box was normal t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments icy 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owner's Name information is OStervllle required for every MA 02655 4/26/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal. drywells 25x13x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts I. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt-Tempies Condo's :buildin #1 A&B&E 3 units Owner Owners Name information is required for every OStervllle MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The Drywells had a 1' of liquid on the bottom A camera was used to inspect 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.): n/a t5insp.doe-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is OStervllle required for every MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts :.. Title 5 Official Inspection Form V l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is required for every OSterville MA 02655 4/26/2021 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 14. ,Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 a O o O O A Q y 3 y 3l� 33 339 33 Y ySE�6 &b S- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I • <10N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's -building#1 A&B&E, 3 units Owner Owners Name information is OSterville required for every MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ` ❑ Check cellar ❑ Shallow wells +/- Estimated depth to high ground water: 28' 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: Topo and water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 l Commonwealth of Massachusetts ,l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 A&B&E, 3 units Owner Owners Name information is Osterville required for every MA 02655 4/26/2021 page. Cltyrrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =' 234 Parker Road Property Address ? Aunt Tempies Condo's Building #2 -Joe & Linda Touzin Owner Owner's Name information is OStervllle K. required for every MA 02655 4/10/2019 p page. City/Town State Zip Code Date of Inspection r,p 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: forms When fillip out f A. Inspector Information f on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services LLC use the return key. Company Name P.O. Box 49 vTkA Company Address Osterville MA 02655 Cltyrrown State Zip Code � 508-862-9400 S 12482 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 4/12/2019 Inspec Signa ure Date The s m inspect r shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts g Title 5 Official Inspection Form f- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe& Linda Touzin Owner Owners Name information is required for every OStervllle MA 02655 4/10/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is Osterville required for every MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............, 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. Cityrrown 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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. ❑ ® 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. 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 CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts - 6? Title 5 Official Inspection Form (n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is OSteNille required for every MA 02655 4/10/2019 page. Cityrrown 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 N/A) ❑ ® Was the facility.or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name required for is every Osterville required for eve MA 02655 4/10/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 2 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, El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): , Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped yearly Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Ostervllle MA 02655 4/10/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road L Property Address Aunt Tempies Condo's Buildin #2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: n/a 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: 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I t5insp.doc•rev.M6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form �- & Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information isequired or every very OSterville MA 02655 4/10/2019 page. City/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): N/a 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): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 f c Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 2 4 3 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information equir for is every Osterville required for eve MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a 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 n/a 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 - 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for 9 P y Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The Pit was dry and clean There were no signs of failure.The bottom to grade was 8'The cover was to grade. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 with overflow Depth—top of liquid to inlet invert 1' below Depth of solids layer 5" Depth of scum layer 1" Dimensions of cesspool 5'x 5'x 6' BTG Materials of construction Cesspool block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool had 4' of liquid on bottom. Outlet tee was present. The cover was to grade. This flows to leach it. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owner's Name information is OStervllle required for every MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I . Commonwealth of Massachusetts �d g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... 234 Parker Road V ' Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is Osterville required for every MA 02655 4/10/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately -77 IT Q Q A � a► as 6 6 1� y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts V p Title 5 Official Inspection Form f- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments U- 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe & Linda Touzin Owner Owners Name information is required for every Osterville MA 02655 4/10/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25 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: topo and water contours map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above A Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I C Commonwealth of Massachusetts P Title 5 Official Inspection Form_ p o m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. 234 Parker Road Property Address Aunt Tempies Condo's Building#2 -Joe& Linda Touzin Owner Owners Name isrequired for every Osterville MA 02655 4/10/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Commonwealth of Massachusetts �AD' U.0 Id 00IA rA1. Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 `._; Owner Owner's Name - — information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return Company Name key. P.O. Box 49 r� Company Address Osterville MA 02655 City/Town State Zip Code few 508-862-9400 S 12482 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 valuation by the Local Approving Authority 4 ❑ Fails 5/24/2021 Insp tor's Signature Date The stem inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L.- 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone. 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4 System Failure Criteria Applicable to All Systems: Y pp Y You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 I ' Commonwealth of Massachusetts ,� Title 5 Official Inspection Form 111 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road u Property Address Aunt Tempies Condo's :building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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. ❑ ® 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. 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 CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply �l ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts e Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 1 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Description: system is a 1 bedroom unit Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 234 Parker Road Property Address Aunt Tempies Condo's building#2. Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped yearly for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterviile MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed on date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I r • Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I ............c� j 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: n/a 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: 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f - Commonwealth of Massachusetts �v Title 5 Official Inspection Form lI p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/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): N/a 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): N/a Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): . N/a *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 n/a 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.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I li Commonwealth of Massachusetts Title 5 Official Form Inspection p _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments c 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 • c Commonwealth of Massachusetts �M Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit was dry and clean. There was no sign of failure. The cover was to grade. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 with overflow Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer 1 Dimensions of cesspool 5'wx5'tx6'BTG Materials of construction block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The cesspool had 4' of water on the bottom. The cover was to grade. t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 L • Commonwealth of Massachusetts Iti Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 • c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road V Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 a a l� a3 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r - - i` • c Commonwealth of Massachusetts Title 5 Official Inspection Form i1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �4 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑. Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 28 +/- 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: Topo and water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#2 Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityffown 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 M . t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Commonwealth of Massachusetts I-OOR I9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Di Assessments 234 Parker Road u� � Property Address F Aunt Tempies Condo's building#1 C&D, 2 units r Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms {� on the computer, 4 use only the tab James Ford key to move your Name of Inspector cursor-do not use the return Ford Septic Services, LLC key. Company Name P.O. Box 49 rab Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 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: I. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further aluation by the Local Approving Authority 4. Fails Inspect ignature 5/24/2021Date The s st m inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is required for every Osterville MA 0 ' 2655 page. City/Town 4/26/2021 State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. _ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 19 Title 5 Official Inspection Form a < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth f o Massachusetts Title 5 Official Inspection Form XSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (conw ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D 2 units Owner Owners Name information is required for every OSterville MA 02655 4/26/2021 page. Cityrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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. ❑ ® 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. 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 CA. Yes No ❑ ® the system'is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply w. p pp y well I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -p y Not for Voluntary Assessments � y 234 Park er Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is psterville required for every MA 02655 4/26/2021 page. Cltyrrown 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 N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 234 Parker Road Property Address Aunt Tem ies Con do s building#1 C&D, 2 units Owner p q Owner's Name information is required for every Osterville MA 02655 page. City/Town 4/26/2021 State Zip Code Date of Inspection D. System Information 1. Residential Flow.Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Description: system is 2- 1 bedroom units Number of current residents: unknown 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts v ,p Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road V� Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner information is Owners Name required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped yearly for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road v Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed on date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owner's Name information is required for every Osteryille MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene _ ❑ other(explain) n/a If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I Commonwealth of Massachusetts �v Title 5 Official Inspection Form y`! Subsurface Sewage Disposal System Form =Not for Voluntary Assessments � f 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. CityTrown 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): N/a 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 El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �Y Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9.1 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): n/a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is OSterville required for every MA 02655 4/26/2021 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries` number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f b Susurace Sewage Disposal System Form - Not f Y or Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D 2 units Owner Owners Name information is Osterville required for every MA 02655 4/26/2021 page. City/Town State " Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The overflow cesspool was dry. no sign of failure A camera was used to inspect 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 with overflow Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer " 1" Dimensions of cesspool 5'w x 8't x 10'bt Materials of construction block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The cesspool had 4' of liquid on the bottom The cover was to grade. t5ins .doc•rev.7/26/2018 p Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 F L Commonwealth of Massachusetts Title 5 Official Inspection Form k Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's buildin #1 C&D, 2 units . Owner Owners Name information is Osterville required for every MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owner's Name information is Osterville required for every MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately rs ai 3y. Frou ' t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 28' +/- 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: Topo and water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Bch., 234 Parker Road Property Address Aunt Tempies Condo's building#1 C&D, 2 units Owner Owners Name information is OStervllle required for every MA 02655 4/26/2021 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 t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road � 1 S Ay-- 4-`1" Property Address "- —�, Aunt Tempies Condo's buildings#3&4, 2 units E` Owner Owner's Name — information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection r , 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:out forms A. Inspector Information filling out forms on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return Company Name key. P.O. Box 49 lllb�" Company Address Osterville MA 02655 City/Town State Zip Code ,ten 508-862-9400 S 12482 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 5/24/2021 s Inspe o Signature Date The s m inspector shall submit a copy of this inspection report to the Approving Authority (Board of He 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 ,i 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 AAAAV conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 V c Commonwealth of Massachusetts Title 5 Official Inspection Form �i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 234 Parker Road Property Address Aunt Tempies Condo's :buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I / Commonwealth of Massachusetts �n Title 5 Official Inspection Form _ cci, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 234 Parker Road u Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I i Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public.water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool .t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I x Commonwealth of Massachusetts Title 5 Official Inspection Form 5 I1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road u- Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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. ❑ ® 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. 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 CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �M ,tip Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page., City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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)] V t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 s Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 234 Parker Road ' Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440, Description: system is 2-2 bedroom units Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑'Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped yearly for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form JSubsurface Sewage Disposal System Form Not for Voluntary Assessments u- 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Y ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed on 11/1/2001 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �v l Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ !% 234 Parker Road Property Address Aunt Tempies Condo's :buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityfrown . State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 20"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: 2 Distance from top of sludge to bottom of outlet tee or baffle 25 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 12 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 Tees were present. There was no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .��6 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown 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): N/a 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): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� _ FI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............., 234 Parker Road V� Property Address Aunt Temples Condo's buildings#3&4, 2 units Owner Owner's Name information is Osterville MA 02655 4/26/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *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 Even 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.): The D-box was clean. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3-500 gal. drywells 33xl3x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �v ►� Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityfrown State Zip Code , Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The Drywells were dry and clean. There was no sign of failure. A camera was used to inspect. 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.): n/a i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments .............c� !% 234 Parker Road u� Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Y I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............c� 234 Parker Road Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3oa � 3. y 30 lq rg 6 t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ !% 234 Parker Road Property Address Aunt Te_mpies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 28 +/ 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: Topo and water contours maps ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form rr I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road u- Property Address Aunt Tempies Condo's buildings#3&4, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 page. CityrTown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name �- information is required for every OStervllle MA 02655 4/26/2021 t page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: forms 4 When fillip out f A. Inspector Information 5 gy 3 f on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return key. Company Name P.O. Box 49 ran Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 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 ❑ Fails 5/24/2021 Insp c is Ignat a Date The stem inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. . t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 234 Parker Road Property Address Aunt Tempies Condo's building.#5 A&B, 2 units Owner Owner's Name information is required for every Osterville MA 02655 4/26/2021 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: ® 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: 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): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 ti Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 1 I Commonwealth of Massachusetts I� Title 5 Official Inspection Form `la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is Osterville required for every MA 02655 4/26/2021 page. 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no.acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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. ❑ ® 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. 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 CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , f 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B 2 units Owner information is Owners Name required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees; material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) t5insp.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts 11� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B 2 units Owner Owners Name information is required for every Osterville . MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: system is 2-2 bedroom units Number of current residents: unknown 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped yearly for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: , gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B 2 units Owner Owners Name information is required for every OSterVllle MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or noj(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed on 11/6/2001 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is Osterville required for every MA 02655 4/26/2021 page. Clty[Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 10" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene y El 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: 2 Distance from top of sludge to bottom of outlet tee or baffle 25 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 12 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 Tees were present. There was no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official - I Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is required for every Osterville MA 02655 4/26/2021 page. Cltyrrown 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_ y ❑ other(explain): N/a 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): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is required for every Osteryille MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/a 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 Even 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.): The D-box was clean. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name information is Ostervllle required for every MA 02655 4/26/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: - ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: r Type: ❑ leaching pits number: ® leaching chambers number: 3-500 gal. drywells 33x13x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name. information is required for every Osterville MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The Drywells were dry_and clean. There was no sign of failure A camera was used to inspect 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.): n/a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 II Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � w 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B 2 units Owner Owners Name information is psterville required for every MA 02655 4/26/2021 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owners Name isrequired for every Osteryille MA 02655 4/26/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately y O 03 A+R �a A Q a 1 A, o 3 y t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 IL Commonwealth of Massachusetts Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` •. 234 Parker Road —.�- Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owner's.Name information is every Osterville required for eve MA 02655 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 28' +/- 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: Topo and water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation:. see above F Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doo-rev.�7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 IL t } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 234 Parker Road Property Address Aunt Tempies Condo's building#5 A&B, 2 units Owner Owner's Name information is required for every Osterville NIA 02655 4/26/2021 page. CitylTown 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 M f t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L _ Commonwealth of Massachusetts r- p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments 234 Parker Road `Property Address Aunt Tempies Condo's units 5 A&B rWa Owner Owners Name information is required for every Osterville MA 02655 2/9/2019 ! page. City/Town State Zip Code Date of Inspection 6+; Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, S"1•f f" f use only the tab 1. Inspector: key to move your cursor-do not James Ford key the return Name of Inspector Y Ford Septic Services LLC r� Company Name P.O. Box 49 Company Address � Osterville MA 02655 ity/Town State Zip Code 508-862-9400 S 12482 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 ❑4NeedFEvaluation by the Local Approving Authority 2/9/2019 Ins Date Thor 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 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. i; t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts o Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owner's Name information is required for every Osterville MA 02655 2/9/2019 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c, 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name required for is every Osteryille required for eve MA 02655 2/9/2019 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if - pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 z Commonwealth of Massachusetts (P Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v / 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name required for is every Ostervllle required for eve MA 02655 2/9/2019 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form �- S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name required for is every Osterville required for eve MA 02655 2/9/2019 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units-5 A&B Owner Owner's Name information is required for every Osterville MA 02655 2/9/2019 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 t Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 1 Commonwealth of Massachusetts p Title 5 Official Inspection Form ( S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name information is OSterVllle required for every MA 02655 2/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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 f Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name information isequired or every Osterville MA 02655 2/9/2019 page. Citylrown 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: Pumped yearly for maintenance 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): 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts A Title 5 Official Inspection Form ( Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name information is required for every Osterville MA 02655 2/9/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed date- 11/6/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i 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: 1 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form j- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owner's Name information is required for every Osteryille MA 02655 2/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 10 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 Tees were present. The liquid level was even with the outlet invert. There was no sign of leakage. The outlet cover was 3" below Grease Trap (locate on site plan): Depth below grade: N/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t7; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 234 Parker Road U— Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name information ati is every Osteryille required for eve MA 02655 2/9/2019 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: N/a 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.): f *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts r� p Title 5 Official Inspection Form _ S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name information is required for every Osterville MA 02655 2/9/2019 page. Cityrrown 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 even 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.): The D-box was normal. 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.): N/a *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form SSubsurface Sewage Disposal System Form - Not for Voluntary Assessments u 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name required for is every Osteryille required for eve MA 02655 2/9/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-500 gal.drywells 33x13x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The Drywelis were dry and there were no sign of failure. A camera was used Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/a Depth—top of liquid to inlet invert Depth of solids layer r Depth of scum layer Dimensions of cesspool Materials of construction A Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts 'n g Title 5 Official Inspection Form }?� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • � 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name information is required for every Osterville MA 02655 2/9/2019 page. CityRown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 :z Commonwealth of Massachusetts �. .. P Title 5 Official Inspection Form F' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owners Name required for is every Osterville required for eve MA 02655 2/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Sec�N� AUK. y 0 0 3 A Q r ' a a I ► lS 3 i t5ins.doc•rev.6/16 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 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owner's Name information is required for every Osterville MA 02655 2/9/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25' groundwater 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: Topo and water contours map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments *., 234 Parker Road Property Address Aunt Tempies Condo's units 5 A&B Owner Owner's Name information is required for every Osterville MA 02655 2/9/2019 page. Cityfrown 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 I t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i Certified Mail#7006 0810 0000 3524 8530 �O*IKE r0 Town of Barnstable C '— Regulatory Services BARNS TABLE, �$ MASS. `��° Thomas F. Geiler, Director ArE0MA�A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 ��_d� Office: 508-862-4644 Fax: 508-790-6304 r February 23, 2007 Tia Ierardi P.O. Box 236 Osterville, MA 02655 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 234 Parker Road, Osterville was inspected on February 9, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.351 - Owner's Installation and Maintenance Responsibilities. Open ground in GFCI outlet in kitchen. 105 CMR 410.401(A) - Ceiling Height. Ceiling height observed at 6'9" throughout P/ apartment. 105 CMR 410.500 - Owner's Responsibility to Maintain Structural Elements. , Exposed insulation at site of wall repair. QAOrder letters\Housing violations\Rental ordinance\234 Parker Road Unit 1B i i You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by finishing repair work on area in living room; by bringing ceiling height to 7'0" as required by 105 CMR 410.401(A); by either grounding GFCI outlet or replacing it with a two prong outlet. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Karen Austin, Tenant Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\234 Parker Road Unit 1B a COMPLETESEND EW� •N COMPLETE THIS SECTION,ON . ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired: X ❑Agent ■ Print your name and address on the reverse v ❑Addressee so that we can return the card to you. B. Received by(P nted Name) at of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 11 t3k9s 1. Article Addressed to: If YES,enter delivery address below: ❑No M 3. Service Type S� C\.\�� l`�� b?fobs E-Certified Mail ❑Express Mail ❑Registered ISLRetum Receipt for Merchandise ❑Insured Mail ❑C.C.D. 4. Restricted Delivery?(Extra Fee) ❑Yes `2. Article Number 7 0`�6 0 81'0` 0 0 0 D! 3 5 2 4'`8 5¢3 0 F f (rmnsfer from service labeQ PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATECROM SORMIDE MA 02r'S ,.... uad: Mt • Sender. Please print your name, address, and ZIP+4 in this box• + c\j JTown of Barnstable Health Division 200 Main Street Hyannis,MA 02601 -4- j; fbMi !/liii'!! !!!i!!f ! hilt !!!! !!!!f 1111illi iil.,011 Certified Mail#7006 0810 0000 3524 8530 �o4z rO�a Town of Barnstable �P d Regulatory Services BARN SrABLE', 900 IM9. ��� Thomas F. Geiler,Director prf1639. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 February 23, 2007 Tia Ierardi P.O. Box 236 Osterville, MA 02655 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY CODE.II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 234 Parker Road, Osterville was inspected on February 9, 2007 by Timothy O'Connell, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.351 - Owner's Installation and Maintenance Responsibilities. Open ground in GFCI outlet in kitchen. 105 CMR 410.401(A) - Ceiling Height. Ceiling height observed at 6'9" throughout apartment. 105 CMR 4 - '10.500 Owner's Responsibility to Maintain Structural Elements. Exposed insulation at site of wall repair. QAOrder letters\Housing violations\Rental ordinance\234 Parker Road Unit I You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by finishing repair work on area in living room; by bringing ceiling height to 7'0" as required by 105 CMR 410.401(A); by either grounding GFCI outlet or replacing it with a two prong outlet. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Karen Austin, Tenant Cc: Timothy O'Connell, Health Inspector QAOrder letterMousing violations\Rental ordinance\234 Parker Road Unit 1B J Certified Mail#0000 0000 0000 0000 0000 T T Town of Barnstable Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 ^�~ Office: 508-862-4644 Fax: 508-790-6304 date 2 y �narne addr. city,state,zip NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at o1 3 was inspected (Address) on�� d by U , Health Inspector for the Town (date) (Inspector's n e) of Barnstable, (Reason for inspection) The following violation(s) of the State Sanitary Code were observed: State code violation number- iolation Qscriptiqn f 105 CMR 410. 5 oU 105 CMR 410. A=k 105 CMR 4 in. 105 CMR 410. Q:\Order letters\Housing violations\Rental ordinance\template.doc as 105 CMR 410. The following violation(s) of the Town of Barnstable Code were observed: (Town code violation number-violation description) §170-_- §170-_- You are directed to correct the violations listed above within (3) days.. #) , 1 ) of your receipt of this notice by (written (# r 7� � ToS C-rl p. qv 1 (A vv✓ ITN/1 You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean,R.S., CHO Director of Public Health Town of Barnstable Cc: (Name,tenant,owner,Fire Dept.,Building Dept....) Cc- TO (Health inspector's name) (Generic codes located at QAOrder letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC) QA0rder letters\Housing violations\Rental ordinance\template.doc � a FORM30 HOBBSBWARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD O ALTH CITY/TOWN W DEPARTMENT ;�G1 ByO� ADDRESS `I 7 M TELEPHONE Address 3 � '1"`\. ---Occupant—. Floor. Apartment No. _No. of Occupants—/ No. of Habitable Rooms _No.Sleeping Roomsj___�� No.dwelling or rooming units—Mt-1 No.Stories— _ Name and address of owner _ lQ/l. 4 Remarks Reg. Vio. YARD Out B d s.: Fences: d Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches.- Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin °'l16 . �U Hall Lighting: - Sn'U I Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Win oors Floors Locks Kitchen " Bathroom _ I { Pantry Den Living Room Bedroom 1 i Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: St ks, Flues,Ve Safeties: Kitchen_Facilities 6ink ---� Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other-.— Egress Dual and Obst'n: General Building Posted OltAea� Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELLBEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE A.M. DATE TIME V - A.M. THE NEXT SCHEDULED REINSPECTION �� P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders there inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ea ------------ d-Nto r Parcel Detail Page 1 of 3 HL CN <t e u k Logged In As: Parcel Detail Thursday, Febru Parcel Lookup Parcel Info Parcel ID 1116 -061-006 Condo Unit UNIT 1 B Condo __—_u.____ Complex JAUNT TEMPY'S Building BLD 1 Location j234 PARKER ROAD Pri Frontage' ------ ---._- Sec—....-- ------- ----- .-._.__.gg Sec Road SECOND AVENUE I Frontage Village IOSTERVILLE Fire DistrictC-O-MM Sewer Acct[ Road Index�1210 Interactive R Map .. -- Owner Info Owner IERARDI,TIA L Co-owner Streetl ;BOX 236 Street2 City pOSTERVILLE State jMA zip j02655 country SUS Land Info Acres j0 useCondominiu MDL-05 zoning SRC Ngnbd0001 Topography Road I Utilities j Location Construction Info Building I of 1 Year 1980 Roof Gable/Hip Ext Wood Shingle Built? 1 Struct Wall i Effect ._. ___.....__� Cooer I _...p ...._ P T pe .:. _._..__—... 412 As h/F GIs/Cm iNone Area�- style'Condominium Int'Drywall Bed 2 Bedrooms =_----...._.._ ..__._.. Wall i_.—_-- -------.. Rooms I__ _.... Int F ...,.._ _..._ Bath i _ __, _ _. ,_....... Model;Res Condo Floor Rooms{ http://issgl/Intranet/propdata/ParcelDetail.aspx?ID=6628 2/8/2007 Parcel Detail Page 2 of 3 "-� Heat,_... ..�...__Y..,�� _.._,_...... Total Grade Average ;Typical 3 Rooms E. Type Rooms 4 _�,....�._..d Heat,!----. ._..... ..�.... Found- Stories 1 Story 1 Fuel' ation ! Permit History Issue Date Purpose Permit# Amount Insp Date Comments __ Visit History Date Who Purpose 7/12/2006 12:00:00 AM Jason Streebel Abatement Review Sales History Line Sale Date Owner Book/Page Sale P 1 7/1/2004 IERARDI, TIA L 18789/144 2 9/29/1998 WEIBEL, KAYBETH 11731/161 3 4/15/1986 DIGIOVANNI, JOHN R 5041/150 4 4/15/1984 LASKY, JEFFREY S 4067/267 5 11/15/1983 LESSA, SYLVIO 3919/001 6 10/15/1983 SIEGEL, 7 CONFIRMATORY DEED 4926/023 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2006 $179,600 $0 $0 $0 2 2005 $152,000 $0 $0 $0 3 2004 $123,200 $0 $0 $0 4 2003 $81,700 $0 $0 $0 5 2002 $81,700 $0 $0 $0 6 2001 $81,700 $0 $0 $0 7 2000 $63,700 $0 $0 $0 8 1999 $63,700 $0 $0 $0 9 1998 $63,700 $0 $0 $0 10 1997 $38,100 $0 $0 $0 11 1996 $38,100 $0 $0 $0 12 1995 $38,100 $0 $0 $0 http://issgl/Intranet/propdata/ParcelDetail.aspx?ID=6628 2/8/2007 Parcel Detail Page 3 of 3 13 '1994 $38,300 $0 $0 $0 14 1993 $38,300 $0 $0 $0 15 1992 $43,600 $0 $0 $0 16 1991 $68,700 $0 $0 $0 17 1990 $68,700 $0 $0 $0 18 1989 $68,700 $0 $0 $0 19 1988 $56,100 $0 $0 $0 20 1987 $56,100 $0 $0 $0 21 1986 $104,900 $0 $0 $0 Photos http://lssgl/Intranet/propdata/PareelDetail.aspx?ID=6628 2/8/2007 j coLn n-t c � ram/ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION Sys RECEIVED JUN 2 9 2004 TITLE 5 TOWN� H LTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS ESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION VAAP Property Address:234 Parker Road,Bldg 1,Units AA,E Osterville �j PARCEL00 7f ; :_�_ . Owner's Name: Aunt Tempy's Condominium Trust LOT Owner's Address: %Huntingest Management,40 Industry Road,Marstons Mills,MA 02648 Date of Inspection: 06/16/04 Name of Inspector:Brian T.Axon Company Name:A&K Septic Systems Plus Mailing Address: 565 Carriage Shop Road East Falmouth,MA 02536 <-� r) Telephone Number: 508-540-6706 CERTIFICATION STATEMENT CD I certify that I have personally inspected the sewage disposal system at this address and that the kf rmation port? below is true,accurate and complete as of the time of the inspection. The inspection was perfor based onjny training and experience in the proper function and maintenance of on site sewage disposal systems I am a DEP Ur approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syst r N r.> G- X Passes W r n Conditionally Passes ti Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 06/18/04 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. Notes and Comments: System functioning fine. There is no evidence of failure criteria. System consists of 1500 gallon tank with d-box and galleys for leaching. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address hoI the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 3I0 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratian or tank failure,is imminent. System will pass inspection if the. existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is.removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the.Hoard of Health): broken pipe(s)are replaced obstruction is removed b ND explain: Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 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 functloaing iu a manner which will protect,public.health,.safety and the.environ.ent-, _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 fee of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is.functioning in a mauner 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 I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. - 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ x 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 r,logged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped x Any portion of the SAS,Eesspool or privy is,below high grwad water e_levation.. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary-to a surface water supply. x Any portion of a cesspool or privy is within a Zone I of a.public well. x Any portion of a cesspool or privy is within 50 feet of a private water supply well. x Any portion-of a.Qesspool or privy is.less.than 1 QQ feet but,greater than SQ feet.from a.private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are.triggered.A F.opy of the,analysis.in-vst.be,attached to this faem�l no (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 1515.303,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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes."in Section D above.the.large.system has.failed. The.owner or operator of any large,system considered a 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection:06/16/04 Check if the following have been done. You must indicate"yes'or"no"as to each of the following: Yes No X — Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X — Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _ x Were as built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? x i Were all system components,excluding the SAS, located on site? x _ 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? X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. X_ , Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance.is.unacceptable)[3.10 CUR 15.302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:234 Parker Road,Bldg 1,Units AB,E Owner:Aunt Tempy's Condominium Trust Date of Inspection:06/16/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual) :3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 5 Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system(yes or no):no[if yes separate inspection required] Laundry system inspected(yes or no):no Seasonal.use:(yes or no): 1 unit year round,2 units seasonal Water meter readings,if available(last 2 years usage(gpd)):NA Sump pump(yes or no):no Last date of occupancy: current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Crease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Nan-sanitary waste.discharged to the.Title.5 system(yes.or na):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:no information available Was system pumped as part of the inspection(yes or no):no Xyes,volume pumped:,How was quantity pumpeddetermined? ' Reason for pumping: TYPE OF SYSTEM • i i X Septic tank, distribution box, soil absorption system Single cesspool ____Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval ____Other(describe): Approximate age of all components,date installed(if known)and source of information: October 2001,project manager Were sewage odors detected when arriving at the site(yes or no):no Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust ' Date of Inspection: 06/16/04 . BUILDING SEWER(locate on site plan) „ Depth below grade: Materials of construction: - cast iron 40 PVC_other(explain):. , Distance from private water supply well or suction Iine: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK x locate on site plan] Depth below grade: 2' Material of construction: x concrete_metal—fiberglass_polyethylene „ —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):-(attach a copy of certificate) a Dimensions: standard 1500 gallon tank Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:39" Scum thickness: 1" Distance.from top of scum to top of outlet tee.or baffle.: S" Distance from bottom of scum to bottom of outlet tee or baffle:11" How were dimensions determined: field instruments Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.):Recommend pumping every two years.Liquid levels in relation to tees are.fine..No evidence.of leakage. Structural integrity is.fine.. GREASE TRAP: NA(locate on site plan) . 7. Depth below grade:_ Material of construction: concrete metal—fiberglass—polyethylene—other (explain): — _ k Dimensions: ; Scum thickness ` Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as.related to outlet invert, evidence,of leakage, etc.).: r y _ • Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPERSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 TIGHT or HOLDING TANK: NA (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: x (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.):Distribution box has no evidence of solids carryover or any evidence of leakage. PUMP CHAMBER: . NA(locate on site-plan) Pumps in working order(yes or no): ' Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) —Property Address: 234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 , SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: x leaching chambers,number: at least two Galley chambers leaching galleries,number: - leaching trenches,number,length: leaching fields, number; dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition o vegetation, etc.): Condition of soil and vegetation is fine.No sign of hydraulic failure. Sent video camera from d-box to galley chamber and it had evidence of only a few inches of staining. CESSPOOLS: NA (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: - Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,IeveI of ponding,condition of vegetation,etc.): PRIVY: NA (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.): Page 10 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Road,Bldg 1,Units A,B,E Owner: Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of.the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.,Locate all wells within 100 feet. Locate where public water supply enters the building. oa 6 � a A I 3a1c'' -3 3 3P 3 33' Page 11 of,l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION(continued) Property=Address:234 Parker Road,Bldg-1 Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 SITE EXAM Slope Surface water Check cellar t . Shallow wells Estimated depth to jrowid water 12-feet Please indicate(check)all methods used to determine the hioli=round water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board ofHealth-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Groundwater Survey 1�� ,i 00 Commonwealth of Mass�lchusetts -006 Title 5 Official Inspection Form ao 6- Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments 234 Parker Road units- 1_A,B,E Property Address Aunt Tempy's Condominiums Owner Owners Name information is y required for every Osterville ,':, ' MA 02655 6/2/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When fillip A. General Informatioh Q' on the forms e computer, ° O use only the tab 1. Inspector: key to move your cursor-do not James Ford (' use the return key. Name of Inspector M U19 Company Name P.O. Box 49 Company Address rer� Osterville `; MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number =: License Number ei f; B. Certification I certify that I have personally iri;spected 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: l ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs FurthZEalation,by the Local Approving Authority 6/2/14 Inspec HSignature Date The ys m inspect shall submit a copy of this inspection report to the Approving Authority(Board of H It or DEP)within 30 days of completing this inspection. If the system is a shared system or has a esign 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. l5ins-3/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 !. Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal;System Form-Not for Voluntary Assessments 234 Parker Road units - 1A,B,E Property Address Aunt Tempy's Condominiums Owner Owners Name information is required for every Osterville MA 02655 6/2/14 page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check.,A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in;310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. l; Comments: b 4 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, WWI' ass. Check the box for"yes", "nof,o,r"not determined" (Y, N, ND)for the following statements. If"not determined," please explain ;j The septic tank is metal and' oyer 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 Board4 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): s� E, i1 i F t5ins-3/13 lj Title 5 official Inspection Form:Subsurface Sewage Disposal System•_Page 2 of 17 - it ' t , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposali;System Form- Not for Voluntary Assessments wM 234 Parker Road units- 1A,B,E Property Address b Owner Aunt Tempy's Condominiums Owners Name information is t required for every Osterville MA 02655 6/2/14 page. . City/Town State Zip Code Date of Inspection B. Certification (Cont.)' K ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): FI ❑ Observation of sewage fbsckup 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): v' ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): . � 1 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I , i ❑ 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): Elbroken pipe(s)a'e;:replaced ElY ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i 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 t ❑ rt:Cesspool or privyi is within 50 feet of a bordering vegetated wetland or a salt marsh . i t5ins•3/13 ;I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 '' i Commonwealth of Massachusetts Title 5 Officia jnspection Form Subsurface Sewage Disposal'P.ystem Form - Not for Voluntary Assessments ,M 234 Parker Road units - 1A,B,d Property Address Aunt Tempy's Condominiums '. Owner Owners Name information is required for every Osterville !, ` ' MA 02655 6/2/14 page. City/Town , State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment,, ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 1. 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 s ;ptic 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: t 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 ElDischarge or ponding of effluent to the surface of the ground or surface waters due to an.overloaded or clogged SAS or cesspool ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y Iday flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massy husetts Title 5 Officia`Inspection Form Subsurface Sewage Disposal'S tem Form -Not for Voluntary Assessments ,M 234 Parker Road units- Property Address Aunt Tempy's Condominiums Owner Owners Name + 'information is required for every Osterville MA 02655 6/2/14 page. City/Town ! State Zip Code Date of Inspection B. Certification (cont.) + Yes No t ❑ ® 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 tributa'y_to a surface water supply. ❑ E Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any p®rton of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any pdrtion of a cesspool or privy is less than 100 feet but greater than 50 feet from al 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 cFiain of custody must be attached to this form.] ❑ (AThe 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 neces46ry 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 musf'in,dicate either"yes"or"no" to each of the following, in addition to the questions in Section D. r Yes No t ❑ ❑ 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 systejn is located in a nitrogen sensitive area (Interim Wellhead Protection W Area- PA)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 Sectio6 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 ji i - tt. Commonwealth of Massachusetts Title 5 Official{:,Inspection Form Subsurface Sewage DisposalSystem Form -Not for Voluntary Assessments °�M A,••°`p 234 Parker Road units - 1A,B,E,; ' Property Address i Aunt Tempy's Condominiums Owner Owners Name + information is I; required for every Osterville i` '` MA 02655 6/2/14 page. City/Town i 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:, It. Yes No z ❑ Pumping information was provided by the owner, occupant, or.Board of Health ❑ ® Were an of y the system components pumped out in the previous two weeks? ® ❑ Has the"system received normal flows in the previous two week period? ❑ ® Have la'ge 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? F, t ® El 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? 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: ® ❑ 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 approxirbia.tion of distance is unacceptable) [310 CMR 15.302(5)] isi • D. System Information' Residential Flow Conditions:;. Number of bedrooms (design"): 3 3 ( 9 ): Number of bedrooms (actual); DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 S, i( t5ins•3/13 q Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official alnspection Form Subsurface Sewage Disposal..System Form - Not for Voluntary Assessments 234 Parker Road units - 1 A,B,E o^M SV•Jam.. Property Address J Aunt Tempy's Condominiums . Owner Owners Name information is required for every Osterville - MA 02655 page. Cltyrrown State Zip Code D of Date te of �' ;'� Inspection D. System Information Description: 4 li . a Number of current residents' . unknown Does residence have a garb6age grinder? El Yes ® No Is laundry on a separate sevtrage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected?,' ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): I . Detail: unavaible k Sump pump? I' �. ❑ Yes ® No Last date of occupancy: i currently i Date Commercial/Industrial Flow Conditions: Type of Establishment: ` 1 . Design flow(based on 310 G;MR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): i. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank'*,esent? El 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 :i ,p i f, i Commonwealth of Massachusetts Title 5 Official 'lnsp ection Form Subsurface Sewage DisposahSy'stem Form- Not for Voluntary Assessments ' M 234 Parker Road units- 1A,B,E ' Property Address Aunt Tempy's Condominiums Owner Owners Name information is required for every Osterville r MA 02655 6/2/14 page. City/Town State Zip Code Date of Inspection D. System Information,.(cont.) Last date of occupancy/use;,' , 6; Date Other(describe below): General Information 6 Pumping Records: Source of information: pumped yearly Y. Was system pumped as part;of the inspection? ❑ Yes ® No e!, If yes, volume pumped: 4 gallons f How was quantity pumped determined? 9 Reason for pumping: Type of System: ® Septic tank,,'distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared systm (yes or no)(if yes, attach previous inspection records, if any) R, ❑ 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.Al:tach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 is f: ' is Commonwealth of Massachusetts Title 5 Official ,Inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments 234 Parker Road units- 1A,13,E Property Address Aunt Tempy's Condominiums Owner information is Owners Name Y: required for every Osteryille MA 02655 6/2/14 page. Cltyrrown State Zip Code Date of Inspection D. System Information'(cont.) Approximate age of all comporients, date installed if known)and source of information: installed on 11/4/2001 - per':as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on sit plan): Depth below grade: ? <; feet Material of construction: s: ❑ 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.): t! r Septic Tank(locate on site plan): Depth below grade: 21 feet Material of construction: ti=r ® 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: r ' 2 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I, . . t• , Commonwealth of Mass6thusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road units- 1A,B,E ; Property Address Aunt Tempy's Condominiums '! Owner Owners Name information is required for every Cisterville t MA 02655 6/2/14 page. City/Town State Zip Code Date of Inspection D. System Information,(cont.) Septic Tank (cont.) Distance from top of sludge�tp'bottom of outlet tee or baffle 30 Scum thickness , 4 Distance from top of scum to'top of outlet tee or baffle 6 Distance from bottom of scum`to bottom of outlet tee or baffle 10 is 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. Inlet cover was to grade. Grease Trap (locate on site`plan): li Depth below grade: =' feet Material of construction: 0 concrete ❑ metal ; a ❑fiber lass 9 ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness t. Distance from top of scum tdtop of outlet tee or baffle Distance from bottom of scum.to bottom of outlet tee or baffle Date of last pumping: ,{ :i Date t5ins•3/13 i s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 It i; Commonwealth of Massachusetts ` R Title 5 OfficiaJ'Anspection Form Subsurface Sewage Disposal:�'ys tem Form -Not for Voluntary Assessments 234 Parker Road units- 1A,B,E i Property Address Aunt Tempy's Condominiums Owner Owners Name information is required for every Osterville MA 02655 page. City/Town „ 6/2/14 State Zip Code Date of Inspection D. System InformatidW(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.): It 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 .i ❑ other(explain): N/a h Dimensions: a • Capacity: gallons Design Flow: ��� gallons per day Alarm present: ! ❑ Yes ❑ No 4 s Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): k. Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13" ek Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 4 Commonwealth of Massachusetts Title 5 OfficiaI :lnspection Form Subsurface Sewage Disposa( ystem Form -Not for Voluntary Assessments 234 Parker Road units - 1A,B,E,;. Property Address Aunt Tem 's Condominiums "r Owner Owner's Name information is i required for every. Osterville MA 02655 6/2/14 page. City/Town State ZipCode Date of Inspection D. Systemlnformati6p" (cont.) . Distribution Box(if presentt;m.ust be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or dut of box, etc.): The D-box was normal. lu i i Pump Chamber(locate on site plan): { Pumps in working order. El Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): �i 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): If SAS not located, explain why: t5ins-3/13 Ft Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r t; ` Commonwealth of Massachusetts Title 5 Official,, Inspection Form rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M 234 Parker Road units- 1A,B,E Property Address Aunt Tem 's Condominiums Owner Owner's Name information is =" required for every Osterville MA 02655 6/2/14 page. City/Town r . State Zip Code Date of Inspection D. System Information,(cont.) Type ❑ leaching pits, number: ® leaching chambers number: 2-500 gal. drywells 25x13x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There were no sign of failure A camera was used to inspect 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•3f13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts W Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker Road units- 1A,B,F�: Property Address " Owner Aunt Tempy's Condominiums #` Owner's Name information is required for every Osterville a . MA 02655 page. City/Town State . ZipCode 6/2/14 Date of Inspection D. System Informatiojf(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): , .. Privy(locate on site plan): t Materials of construction: r Dimensions Depth of solids li Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a A f. y t5ins•3/13 �; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14•of 17 Commonwealth of Mass.aehusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'..System Form -Not for Voluntary Assessments 234 Parker Road units - 1A,B,E; Property Address Aunt Tempy's Condominiums ' Owner Owner's Name information is required for every Osterville page. Crty/Town MA 02655 6/2/14 t 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 ❑ drawing attached separately o 3 O A Q 3:� 3S , 3 3 96 33 -Y ys t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i1 -- Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal:System Form - Not for Voluntary Assessments ;M 234 Parker Road units- 1A,B,E ' Property Address Aunt Tempy's Condominiums Owner Owners Name information is required for every Osterville MA 02655 6/2/14 page. City/Town State Zip Code Date of Inspection s . D. System Information,(cont.) Site Exam: + ❑ Check Slope R; ❑ Surface water ❑ Check cellar =s a .• ❑ Shallow wells Estimated depth to high ground water: 20'+/- feet Please indicate all methods used to determine the high ground water elevatioh: ❑ 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: Using topo and water contours maps ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS.database-explain: i+ You must describe how you'established the high ground water elevation: see above • t r' E: ;, i f Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 i' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Mass,Achusetts Title 5 Official Ins pection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 234 Parker Road units - 1A,B,E' Property Address Aunt Tem 's Condominiums Owner Owner's Name information is }, required for every Osterville MA 02655 6/2/14 page. City/Town State Zip Code Date of Inspection E. Report Completen'6ss Checklist f ® 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 .. iir f, i; r; li 6i i+ If e f i I i I ' i; t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 it ti i� COMMONWEALTH OF MASSACHUSETTS Q. EXECUTIVE OFFICE OF ENVIRONMENTRRAIRS > d DEPARTMENT OF ENVIRONMENTAL PE OTlE&&vED A F JUL 13 2004 TOWN OF BARNSTABLE HEALTH DEPT. i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 234 Parker Road,Bldg 1,Units C,D Osterville Owner's Name:Aunt Tempy's Condominium Trust Owner's Address:c/o Huntingest Management,40 Industry Road,Marstons Mills,MA 02648 Date of Inspection: 07/02/04 Name of Inspector: Brian T.Axon Company Name:A&K Septic Systems Plus Mailing Address: 565 Carriage Shop Road East Falmouth,MA 02536 Telephone Number: 508-540-6706 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority_ Fails c-� Inspector's Signature: ' Date: 06/18/04 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. Notes and Comments: System functioning fine. There is no evidence of failure criteria. System consists of main cesspool with overflow. ****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. 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS SESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 234 Parker Road,Bldg 1,Units C,D Owner:Aunt Tempy's Condominium Trust Date of Inspection: 07/02/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 1 ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:234 Parker Road,Bldg 1,Units C,D Owner:Aunt Tempy's Condominium Trust Date of Inspection: 07/02/04 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. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART A Y k. CERTIFICATION(continued) Property Address: 234 Parker Road,Bldg 1,Units C,D Owner:Aunt Tempy's Condominium Trust ; Date of Inspection: 07/02/04 " D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections:. ' Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool x Discharge or ponding of effluent to the surface of the ground or surface waters due to an-overloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow x Required pumping more than 4 times_in the last year NOT due to clogged or obstructed pipe(s),Number of times pumped x Any portion of the SAS,cesspool or privy is below high ground water elevation. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x My portion of a cesspool or privy is within a Zone 1 of a public well. x Any portion of a cesspool or privy is within 50 feet of a private water supply well. x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] no (Yes/No)The system.fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of > Health to determine what will be necessary to correct the failure. E. Large 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large-systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply r 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 t Page 5 of 11 15.304. The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 234 Parker Roa d,Bldg 1,Units C,D Owner:Aunt Tempy's Condominium Trust Date of Inspection:07/02/04 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? --x—Were as built plans of the system obtained and examined?(If they were not available note as NIA) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS, located on site? x _ 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? x Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? i The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `SYSTEM INFORMATION ' Property Address: 234 Parker Road,Bldg 1,Units C,D Owner;Aunt Tempy's Condominium Trust Date of Inspection: 07/02/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual) : 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 ?. Number of current residents: 3 Does residence have a garbage grinder(yes or no): no = Is laundry on a separate sewage system(yes or no):no[if yes separate inspection required] , Laundry system inspected(yes or no): no Seasonal use: (yes or no):yes ` Water meter readings, if available(last 2 years usage(gpd)):NA ` Sump pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):' gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes.or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION r Pumping Records ' Source of information: - Was system pumped as part of the inspection(yes or no):yes , If yes,volume pumped: 1600 How was quaniity pumped determined?estimated Reason for pumping cesspools TYPE OF SYSTEM ____Septic tank,distribution box,soil absorption system, Single cesspool - x Overflow cesspool _Privy Y _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 ti•" ' obtained from system owner) Tight tank ,Attach a copy of the DEP approval ' Other(describe): Approximate age of all components, date installed(if known)and source of information: unknown Were sewage odors detected when arriving at the site(yes or no):no Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Road,Bldg 1,Units C,D + Owner:Aunt Tempy's Condominium Trust Date of Inspection: 07/02/04 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK na locate on site plan) Depth below grade: Material of construction: x concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):=(attach a copy of certificate) Dimensions: standard 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:' How were dimensions determined: field instruments Comments(on pumping recommendations,inlet and outlet tee'®r baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:NA(locate on site,plan) Depth below grade:, Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ,- Property Address: 234 Parker Road,Bldg 1,Units C,D Owner:Aunt Tempy's Condominium Trust Date of Inspection:07/02/04 TIGHT or HOLDING TANK: NA (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: a Comments(condition of alarm and float-switches, etc.): DISTRIBUTION BOX: na (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: NA(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property`Address: 234 Parker Road,Bldg 1,Units C,D Owner:Aunt Tempy's Condominium Trust Date of Inspection: 07/02/04 SOIL ABSORPTION SYSTEM(SAS): x (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: _x_overflow cesspool,number: 1 innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.): Condition of soil and vegetation is fine.No sign of hydraulic failure. CESSPOOLS:_NA (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1-main round I-overflow round Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: main-8 x 8,overflow 6 x 6 Materials of construction: block Indication of groundwater inflow(yes or no): no Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.): Condition of soil and vegetation is fine.No sign of hydraulic failure. PRIVY: NA (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.): f Page 10 of11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Road,Bldg 1,Units C,D Owner: Aunt Tempy's Condominium Trust - Date of Inspection: 61/02/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or. benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. `4 J.S 4 � , r/f o r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Road,Bldg 1 Units C,D Owner: Aunt Tempy's Condominium Trust Date of Inspection: 07/02/04 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained.from system design plans on record-If checked, date of design plan reviewed: _x Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board ofHealth-explain: Checked with local excavators,installers-(attach documentation) _x Accessed USGS database-explain: You must describe how you established the high ground water elevation: Pumped cesspool and no groundwater encountered at 106". USGS groundwater maps show groundwater at 12+ feet. �e . Commonwealth of Massachusetts ' 0(e Odl' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd Unit 1 D PropertyAddress Heidi Lohr Owner Owner's Name/ information is Osterville Ma 02655 ' y 3/12/20 required for every page. City/Town State Zipd C Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael DiBuono - key to move your Name of Inspector cursor-do not use the return DiBuono Sewer And Drain ` _ • key. Company Name 35 Content Lane. + r� Company Address Cotuit Ma 02635. City/Town State Zip Code B� 508-364-9587 SI 13522 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 e 4 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving•Authority 4. ❑ Fails ���..._.-3/13/20 In' pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection .Form 14 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY 234 Parker.rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 3/12/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection,Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ! System contains a brick cesspool and a block over flow cesspool . Liquid level in first cesspool is approximately 18" below invert pipe. Overflow cesspool does not show signs of use if so very little. Both Cesspools are in very good condition. Main cesspool is only handling a bathroom and a kitchen sink from the studio appartment. 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. F 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): L l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18- c Commonwealth of Massachusetts p, Title 5 Official Inspection Form I;o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 3/12/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) u 1 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N' ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if . the system is failing to protect public health, safety or the environment., a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 h Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 234 Parker rd V Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 3/12/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 'System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd Property Address fi Heidi Lohr Owner Owner's Name information is Osterville Ma 02655 3/12/20 required for every ' page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged.or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 0 ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well - t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 r F c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd ` Property Address Heidi Lohr Owner Owner's Name information is Osterville Ma ; - 02655 . 3/12/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes".to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: - P 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 issueEl . 'approximation of distance is unacceptable) (310 CMR 15.302(5)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker rd V� Property Address , Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 3/12/20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to , F 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 98 Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every. Osterville Ma 02655 3/12/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑"No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use, Date Other(describe below): 3. Pumping Records: Source of information: Pumped in 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 ' 3/12/20 page. City/Town State Zip Code Date of Inspection D. System Information. (cont.) 4. Type of System: ❑. Septic tank, distribution box, soil absorption system ® a Single cesspool. ® Overflow cesspool ❑ Privy A ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: ` Original to home Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: I 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 * " 3/12/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 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: 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma d2655 3/12/20 page. City/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): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. . Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name T information is ,. required for every Cisterville Ma 02655 3/12/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA R 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.): 1. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 . 3/12/20 page. City/Town State Zip Code, Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: ❑ Yes ' ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits, number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ - leaching fields number, dimensions;; ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts ,IF Title 5 Official Inspection Form �4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 3/12/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) . 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Overflow block cesspool has seen very little use if any at all. No significant staining in overflow. .12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 in series Depth—top of liquid to inlet invert. App 18" Depth of solids layer lit a Depth of scum layer 6" Dimensions of cesspool 6'x6' Materials of construction Brick Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of failure. Cesspool is functioning as designed t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is Osterville required for every Ma 02655 3/12/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts x Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments emu, 234 Parker rd " Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville May 02655 3/12/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 �l�zZ/ z o Q O �F 0 VL Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 234 Parker rd Property Address Heidi Lohr Owner Owner's Name information is required for every Osterville Ma 02655 3/12/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ' ❑ Surface water, ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feeetet ft Please indicate all methods used to determine the high ground water,elevaiion: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Maps indicate ground water at approximately 15' t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 � w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 234 Parker rd u� Property Address Heidi Lohr Owner Owner's Name information is Osterville Ma 02655 3/12/20 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist s Complete all applicable sections of this form inclusive of: El 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 d .r t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 J GrAd D.E.P. Title V Septic Inspector - RO. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI, Lt.Governor 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION ell 234 Parker Rd.Unit 2 Aunt Tem s Condominiums PropertyAddress: Py' '�1c Address of Owner: ro O Date of Inspection: 718/98 �f�f/ll(if different) yo� sj Name of Inspector: John Grad PropertyProperty Manager yF9��1999 l I am a DEP approved system inspector pursuant to Section 15.340 of Title k(310 CMR 15.000) �pF2s� 9�C Company Name,Address and Telephone Number: r9B�F - Ep CERTIFICATION STATEMENT 9 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is rue, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes This inspection Is based on criteria dented In Title V x Conditi0 ally asses code 310CMR16303.My findings are of how the system Is performing atthe time of the inspection.My Inspection does — Needs urt r Evaluation By the Local Approving Authority not imply any warranty or guarantee of the longevity of the Fells septic system and any of Its components useful life. Inspector's Signature: UN Date: 7120198 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: r + t , Check A, B,,C,or D: t a A] SYSTEM PASSES: —I have not found any information which indicates that the system violates any of the failure criteria defined as in.310 CMR 15.303. Any failure criteria not evaluated are indicated below. } ; COMMENTS: B] SYSTEM CONDITIONALLY PASSES: a . x One or more system components need.to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of — CoMpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised04127197) ' One Winter Street •`Boston,Massachusetts 02108 . FAX(617)556-1049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A F CERTIFICATION (continued) doml iums • 234 Parker Rd.Unit 2 Aunt Tem • n Property Address. PYs Con Owner: Property Manager Date of Inspection:718199 _ Sewage backup or.breakout or hiah.static water level observed.in.the distribution box is due to a broken; or obstructed pipe(s)or due to broken,settled or uneven distribution,box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced' The system required pumping more than four times 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 a obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING 1N A MANNER THAT PROTECT,THEPUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Y 4 - The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply: — The system has a septic tank and soil absorption system and is within a Zone 1 of a public,watersupply well. ti The system has aseptic tank and soil absorption system and is within 50 feet of a.private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria"as defined in 4. 310 CMR 15.303. The basis for this determination is identified below. The Board.of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or r cesspool: Discharge or ponding of effluent to the'surface of the ground or surface waters due to an overloaded o(clogged cesspool. _ +. ' . SAS is in hydraulic failure. (revised 04127/97) e a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 234 Parker Rd.Unit 2 Aunt Tempy's Condominiums Owner: Property Manager Date of Inspection:718198 D] SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow: Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped t, s Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. 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. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area(IWPA)or a mapped Zone Il of'a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program n requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 234 Parker Rd.Unit 2 Aunt Tempy's Condominiums Owner: Property Manager w Date of Inspection:718198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and'examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x— — The site was inspected for signs of breakout: x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of, Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. _ x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)1 (revised 04117)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 234 Parker Rd.Unit 2 Aunt Tempy's Condominiums Owner: Property Manager Date of Inspection:71e198 FLOW CONDITIONS RESIDENTIAL: ; Design flow: 220 g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(god): Na I Sump Pump(yes or no): No N - Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: nin Design flow:o gallons/day Grease trap present: (yes or no) No - Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nra t. Last date of occupancy: nra OTHER:(Describe) nra , f Last date of occupancy: GENERAL INFORMATION - PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No, If yes,volume pumped:0 gallons N „ Reason for pumping: rua TYPE OF SYSTEM , Septic tank/distribution box/soil absorptions'system ' x Single cesspool Overflow cesspool _ Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) x I/A Technology etc.Copy of up to date contract? Other: overflow precast leach pit ' APPROXIMATE AGE of all components,date Installed(if known)and source information: ' New leach pR was Installed In 1962 • - _ - ' - ._ Sewage odors detected when arriving at the site:(yes or no) No (revlsed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Rd.Unit 2 Aunt Tempys Condominiums Owner: Property Manager Date of Inspection:719198 SEPTIC TANK: (locate on site plan) l' Depth below grade: rVa Material of constructiom concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance Nc (YeslNo) Dimensions: rya s, + Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: Ma Scum thickness:rite Distance from top of scum to top of outlet tee or baffle:We Distance form bottom of scum to bottom of outlet tee or baffle:rda How dimensions were determined: ride Comments: (recommendation for pumping,condition of inlet and outlet tees or.baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) rda GREASE TRAP: p. (locate on site plan) Depth below grade: nfa Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: Na Scum thickness:rile Distance from top of scum to top of outlet tee or baffle:ride Distance from bottom of scum to bottom of outlet tee or baffle: nia Date of last pumping;,r, w Comments: > (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) rJa BUILDING SEWER: (Locate on site plan) Depth below grade: 9,, Material of construction: cast iron_40 PVC other(explain) Distance from private water,supply well or suction tine?o- Diameter: nia_ Q-1mments: (conditions of joints,venting,evidence of leakage,etc) r+ (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION (continued) a Property Add ress: 234 Parker Rd.Unit 2 Aunt Tempy's condominiums Owner: Property Manager Date of Inspection:718198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rd { Material of construction:—concrete—metal- FRP_Polyethylene 'other(explain) " + Dimensions: n1a Capacity: rJa gallons Design flow: rVa gallons/day r Alarm level:_n1a Alarm in working order?_Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: o1a = f Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) 4 '` Pumps in working order.(yes or no)Nc Alarms in working order(yes or.no)_ve: _r Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised 04127)971 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r ' SYSTEM INFORMATION (continued) Property Address: 234ParkerRd.Unit 2 Aunt Tempy'sbandominiums Owner: Property Manager Date of Inspection:718198 SOIL ABSORPTION SYSTEM (SAS):x ' (locate on site plan,if possible;excavation not required„but may be approximated by non-intrusive methods) If not determined to be present,explain: rda 4 Type leaching pits,number: to00gallonleach pit " leaching chambers, number:Na leaching galleries,number: na leaching trenches, number,length: nta leaching fields, number,dimensions:n1a overflow cesspool,number:n1a Alternate system: rda Name,of,Technology:_n1a ;. Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) The leach pit was structurally sound and functioning property.The leach pit had t'ofwater in it at the time of the Inspection. r CESSPOOLS:x { i (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert:8" Depth of solids layer: 4" ' Depth of scum layer: Dimensions of cesspool Materials of construction: block Indication of groundwater: none r r inflow(cesspool must be pumped as part of inspection) n1a Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Main Cesspool Is structurally unsound,System will pass If cesspool la replaced with aeptic tank PRIVY: ¢. (locate on site plan) Materials of construction: n1a Dimensions: n1a - Depth of solids: n1a ' Comments:(note condition of soil, signs of hydraulic failure,level,of ponding, condition of vegetation,etc.) a n1a a (revlsed OOD97) ,r' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 234 Parker Rd.Unit 2 Aunt Tempy's Condominiums Property Manager 7f8f98 SKETCH OF SEWAGE DISPOSAL SYSTEM: h r include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 17 r, 44 �3 b �a � (revlsed0lf2T197) Page 9 of 10 1 y V - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION(continued) 234 Parker Rd.Unit 2 Aunt Tempy's Condominiums Property Manager , 7r8r98 y. Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole,basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,•installers, x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) z USGS Maps and Charts (revised04RA97) Pago 10 61 10 .\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED 350 MAIN STREET RE EIVED WEST YARMOUTH,MA TOWN OF BARNS 1 16LE 508-775-2800 HEALTH DEPT. SEP TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS HEALTH DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A C:1 —7 3� CERTIFICATION MAP 116 PAR 061 Property Address: 234 PARKER ROAD OSTERVILLE,MA"02655 Owner's Name: CARLA ROY—AUNT TEMPYS Owner's Address: 234 PARKER ROAD OSTERVILLE,MA 02655 MAP l _ - Date of Inspection AUGUST 15,2002Vj PARCEL * 5G T Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco LOT ; Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector'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 tot he buyer,if applicable,and the approving authority. Notes and Comments -BUILDING 2 ****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. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will.pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s): The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 C. Further Evaluation is Required by the Board of Health: N/A 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 salt marsh 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 Zoned of 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 detenmine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: s Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA RAY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or Cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of breakout? X Were all system components,excluding the SAS,located on site? X Were the 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] L. Title 5 Inspection Form 6/15/2000 5 Page 6 of 1 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: N/A Does residence have a garbage grinder(yes or no): N/A 'r Is laundry on a separate sewage system(yes or no): N/A [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use(yes or no): N/A Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) N/A Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: Gallons—How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM X Soil absorption system X Cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): 'Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): N/A Depth below grade: Material of construction: Concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to the 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): s Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ` Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): I Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) w Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarns in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE 1,000 GALLON PRE CAST PIT WITH COVER 8"BELOW GRADE.PIT IS DRY AND CLEAN.WALLS ARE CLEAN,LIKE NEW.NO STAIN LINE. CESSPOOLS: X (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert: 5'6" Depth of solids layer: 2" Depth of scum layer: _ 0" Dimensions of cesspool: 7' Materials of construction: BLOCK Indication of groundwater inflow(yes or no): N/A Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): MAIN POOL T BLOCK WITH CEMENT COVER AT GRADE.ONE LINE IN,NO TEE.ONE LINE OUT WITH TEE. PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of i l OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 PARKER ROAD OSTERVILLE,MA 20655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A'' �2j� 3s o a Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM— FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 PARKER ROAD OSTERVILLE,MA 02655 Owner: CARLA ROY—AUNT TEMPYS Date of Inspection: AUGUST 15,2002 SITE EXAM Slope Surface water Check cellar Shallow wells C� Estimated depth to groundwater feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: AREA HIGH 4 I Title 5 Inspection Form 6/15/2000 11 J Commonwealth of Massachusetts 0 6 Executive Office of Environmental Affairs Dept. of Environmental Protection ,1� Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector lug P.O. 1 Tea ' SG4-G 8 32 � WILLIAM F.WELD A Governor RECEIVED ARGEO PAUL CELLUCCI 0 1 Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM OCT 7 1997 .la PART A TOWN CERTIFICATION 4F6ARNpTA6LE Property Address: 234 Parker Rd.Unit 1 E Osterville Aunt Tempy's CondominiumsAd d ress of Owner: Date of Inspection:9129/97 (If different) 1 1,IF Name of Inspector:John Grad Marsha Shanbarm I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR.15.000) Company Name,Address and Telephone Numbers' CERTIFICATION STAT EMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V — Condition ly Passes code 310 CMR 16.303.My findings are of how the system is performing at the time of the inspection.My inspection does _ NeedsF th Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of its components useful life.Date: 1013/97 Ni Inspector's Signature: - , The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A] SYSTEM PASSES: X• I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion' of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/27/97) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500 Y � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 234 Parker Rd.Unit 1 E Ostervlle Aunt Tempts Condominiums Owner: Marsha Shenbarm Date of Inspection:9/29/97 5ewaae backup or.breakout.or hiah.static water level obser.ved.in.the distribution b.ox is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: , broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. , 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC.HEAL•TH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of,a private watersupply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: a You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this deter mination o' ti n is identified below. The Board of Health Should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or _ cesspool. Discharge or ponding of effluent to the surface of the ground oe surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 234 Parker Rd.UnR 1 E Osterville Aunt Tempys Condominiums Owner: Marsha Shenbarm Date of Inspection:9/291s7 Dj SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. , Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below theihigh groundwater elevation. Any portion of a 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. 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. El LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following,criteria apply to large systems in addition to the criteria: ' The system serves a facility with a design flow_of10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. t i (revised 04127197) . A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B E CHECLIST Property Address: 234 Parker Rd.Unit t E Osterville Aunt Tempys Condominiums Owner: Marsha Shanbarm Date of Inspection:9/29197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ; Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X — The facility or dwelling was inspected for signs of sewage back-up. X — The system does not receive non-sanitary or,industrial waste flow. The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge,depth of scum. X _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. X Existing information. Ex. Plan at B.O.H. X Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is- unacceptable)115.302(3)(b)J e• (revised 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION Property Address: 234 Parker Rd.Unit 1 E Osterville Aunt Tempy's Condominiums Owner: Marsha Shenbarm Date of Inspection:9/29/97 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 110 g•p Number of bedrooms: 5 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): No Seasonal use(yes or no): Yes Water meter readings,if available:(lasst two(2)year usage(gpd): Sump Pump(yes or no): No Last date of occupancy: seasonal use t COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallonsiday Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n/a Last date of occupancy: n/a OTHER:(Describe) nla Last date of occupancy: GENERAL INFORMATION . PUMPING RECORDS and source of information: A ' System has not been pumped in the last year. y System pumped as part of inspection:(yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system , X Single cesspool X Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) VA Technology etc. Copy of up to date contract? Other. APPROXIMATE AGE of all components,date installed(if known)and source information: Aoproximatelty 30 years Sewage odors detected when arriving at the site:(yes or no) No (revised 0427197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 234 Parker Rd.Unit 1 E Osterville Aunt Tempys Condominiums Owner: Marsha Shanbarm Date of Inspection:9/29197 SEPTIC TANK: (locate on site plan) Depth below grade: n/a Material of construction: concreate metal FRP Polyethylene_other(explain) If tank is metal, list age 0 . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: n/a Sludge depth:n!a Distance from top of sludge to bottom of outlet the or baffle: n/a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance form bottom of scum to bottom of outlet tee or baffle:n1a How dimensions were determined: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n/a GREASE TRAP:_ ' (locate on site plan) Depth below grade: n/a Material of construction: _concrete metal FRP Polyethylene—other(explain) Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle:n/a Date of last pumping,v, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n1a BUILDING SEWER: (Locate on site plan) Depth below grade: 2 Material of construction: cast iron 40 PVC_other(explain) Distance from private water supply.well or suction line? ^ ;. Diameter: 4• Framments:(conditions of joints,venting,evidence of leakage,etc.) (revised 04/27197) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contlnued) Property Address: 234 Parker Rd.Unit l E osterville Aunt Tempys Condominiums I Owner: Marsha Shanbarm Date of inspection:9/29197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: We Polyethylene other(explain) Material of construction: concrete_metal_FRP_ -- Dimensions: n/a Capacity: nra gallons Design flow: n/a gallons/day Alarm level:_nia Alarm In working order?-Yes_No ' Date of previous pumping: Comments: r. (condition of inlet tee, condition of alarm and float switches,etc.) n!a DISTRIBUTION BOX: (locate on site plan) " Depth of liquid level above outlet invert: rJe Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n/a PUMP CHAMBER: (locate on site plan) r Pumps in working order.(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n!a a d n (revised 04127/97) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ; SYSTEM INFORMATION(continued) Property Address: 234 Parker Rd.Unit t E Osternlle Aunt Tempys Condominiums Owner: MarsheShanbarrn Date of Inspection:9/29197 SOIL ABSORPTION SYSTEM(SAS):X approximated ti non-intrusive methods) (locate on site plan,if possible;excavation not required,but may be app Y. If not determined to be present,explain: n/a Type leaching pits,number: n1a leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: nle leaching fields,number,dimensions:n/a overflow cesspool.number:6k6'block_ Name of Technology:_n1a Alternate system: n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding; condition of vegetation, etc.) The leach it is stnjctur*L sound and furulionin roe .It was em at the time of the ins ection.Plt has not had more than 1 of water in it. CESSPOOLS:X ' (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: 1 Vel Depth of solids layer: Depth of scum layer. 1° Dimensions of cesspool: TxT Materials of construction: block Indication of groundwater: none inflow(cesspool must be pumped as part of inspection) n1a t Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Mein cesspool and all components are structurally sound.Recommend pumping system every one year for maintenance. PRIVY'_ _r (locate on site plan) Dimensions: n/a Materials of construction: nla Depth of solids: n/a condition of vegetation,etc.) Comments:(note condition of soil,signs of hydraulic failure,level of p onding, n/a (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C . SYSTEM INFORMATION(continued) 234 Parker Rd.Unit t E osterville Aunt Tempy's Condominiums Marsha Shanbarm sn9197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks, locate all wells within 100'(Locate where public water supply comes into house) 4.. r i lap• ! of 10 (revised 0427/97) t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 234 Parker Rd.Unit 1 E Osterville Aunt Tempy's Condominiums Marsha Shanbarm 9/29/97 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation:' Obtained from design plans on record. Observation of Site(Abutting property,,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health' Check FEMA Maps Check pumping records g . Check local excavators, installers x Use USGS Data T Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts , Page 10 of 10 (revised 04/27/97) t Ik-'q. N OF BARNSTABLE C, LOCATION,QN PwuBIZ p SEWAGE # VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264 r -SEPTIC TANK CAPACITY LEACHING FACILITY:(typeY,Q�bD /20 1 S (size) NO.OF BEDROOMS PRIVATE WELL OR�-UBLIC ._ATTEER BUILDER OR OWNER r4n&4 DATE PERMIT ISSUED: g DATE COMPLIANCE ISSUED: ,//' 7" 07 VARIANCE,GRANTED: Yes No F'-L 5 3'{ l0 3\, 3. � �S �, E-0 O U r No. $ _ _ Fee 6^� + THE COMMONWEALTH OF MASSACHUSETT9' Entered in computer: Vs PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zi pprtcation for &.5poal *r5terd Cow6truction Permit i Application for a Permit to Construct( )Repair( ✓4Jpgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. c)3`r Ph-ke I- A 0t Os, Owner's Name,Address and Te No.o �S4, /9U1f leK/>yS � 0 Assessor's Map/Parcel / OW U n`-�- J— — A ' f �� Installer's Name,Address,�pd1C.,tIg,NCO Designer's Name,Address and Tel.No. c 350 Main Street �l VV W Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow :'ST?R 3SO gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /S��o Type of S.A.S. "Z Description of Soil CAr!do �' i LfA- Nature of Re airs or Alterations(Answer when applicable) t 4) , ox Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo of rlth. Signed Date 41 Application Approved by Date t,��$ Application Disapproved for th follo ng reasons Permit No — 19 a- — Date Issued 0- _ U , f. v �. ;�, .. .�--••ems <, . . f " ` 4D s ' l °' •• '= -�?' Fee / •THE.COMMONWEALTH OF MASSA(�•AJaETTS`9`' Ente din"computer. u Xs r PUBLIC HEALTH DIVISION -TOWN OF BARNSTA MASSACHUSETTS ti nation for -i� o aI ip�tent Cow5truction Permit Application€or a,.Per ut.t=o,Construct(„�)Repair( ..)Tpgrade( )Abandon( ) D Complete System El Individual Components t. Location Address or Lot No. :7 3 4K c r ke i A It 0S i Owner's Name,Address and Tel No. / 40✓1+ ltMl>)/S C rfl 1 d o Assessor's Map/Parcel Abk Installer's Name,Addre %NCO • Designer's Name,Address and Tel.No. 350 Main Street W. Yarmouth, MA 02673 Type of.Building: t Dwelling •Nq,lof Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3SO gallons per day. Calculated daily flow gallons. Plan Date. Number of sheets Revision Date Title Size of Septic Tank /Sry 0 Type of S.A.S. `7 1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) S o o !�rj A�• %.g•c1� 7 t� " r Date last inspected: t {{` :Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage.disposal system . in accordant '-with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- t. cate of Compliance has been issued by this Board of lth. \ t Signed i) �t I Date /d - 7- 7`/ Application Approved by Date 1 ) Application Disapproved for th9follovRng reasons l Permit:No. Date,Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS r Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired.( . 'fUpgraded/ Abandoned( )by C ey C o at Q. 3</ i'ke r 12 eC U rle ems./Le Un f- I has been constructed in acFordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated `� 1 Installer Designer The issuance of this pe it shall not be construed as a uarantee that the ste ill fund on a ,desi ned.Date I 1 `� C� guarantee k Q -------------------------------------�^-- .!ZG No. l/ Fee J C� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoga[ *pztem Con6truction Permit Permission is hereby granted to Co truct )Repair( ✓ Upgrade( )Abandon( ) System located at 79. �/' � �r i2��• h Sy`«� X/f and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by � l a v U ��,,• Y �•l.,), ci/ L( �Y 1/6/99 NOTICE: This Form Is To Be Used For the Rep air Of Failed Septic Systems Only.- 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 loZ - S- 99 concerning the property located at a3y .� �� /Z, QSfetu)1 i meets all of the following criteria: .._ The failed system is connected to a residential dwelling only. There are no commercial or business , uses associated with the dwelling. t The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. r � 17 • There are no wetlands within 100 feet of the proposed}septic system There are no private wells within 150 feet of the proposed septic system ] � • There is no increase in flow and/or change in use proposed T� There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the' maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor Z1f ethod when applicable] the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 a• 3 B) G.W. Elevation . F- +the MAX. High G.W. Adjustment. a DIFFERENCE BETWEEN A and B SIGNED J DATE: [Sketch proposed plan of system on back]. q:health folder:cert a�12, L4 c a, .,+ farj•IC',};r"'F,� '� t"N�'-i"`siTRts.�.,..s�2' .a3�ds^ C�'sis-- 7T 'M �{tr u ^�t x-,-ts- ''7z•, ...x 'ry- : t,gxG4A } sJa ? � wh ?x c4k art xfi v, x�au � � { r} TOiWN OE EARNSTABIB (: s„£ i1 Y.00ATION •�A1In SEWAGE # . a VILLAGE -MAP cad r VlC:(: ASSESSOR'S :& LOT' r INSTALLERS NAME & PHONE NO. & B CArK.'0 775-6264 SEPTIC TANK CAPACITY' S� �� t LEACHING FACILITY (type ,�)S �iI�z✓ L[,S (size) ZrX 13� WELL OR LR • , ,.,, ..NO OP.;BED.ROQM;S. PRIVATE , PU LI ATB• BUILDER OR OWNER p rr�tr�fi' DATB PERMIT ISSUED DATB COMPLIANCE ISSUED::. VARIANCB GRANTED. Yes y No �r� t 1TIYt it •}' it 2t•r - l I fy Y 99- Liz- Commonwealth of Massachusetts I W Title 5 Official` Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments wM 234 Parker Road units- 1A,B,E. Property Address 1 Aunt Tem 's Condominiums Owner Owner's Name information is required for every Osterville MA 02655 6/2/14 page. City/Town i State Zip Code Date of Inspection D. System Information (cont.) i 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 o S. .Q .3 a o C�_ o � C3 3�' 36- 3 33 3 3 g6 33 yys3(0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 =%h�. � ��� i, �� '� �� � ' �. . 9��- S� 4 / / /_ ���v�-j�-� C����'� c� L s��� �� - , � �. _ � z . � _ . �. _. ` _ _ _ ���� �� . . i� � - _... _ .. .. . ., ,.. i i i . _ i e10of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:234 Parker Road,Bldg 1,Units A,B,E Owner:Aunt Tempy's Condominium Trust Date of Inspection: 06/16/04 SKETCH OF SEWAGE DISPOSAL.SYSTEM .Provide a sketch.of.the..sewage disposal system including ties to at least two permanent reference landmarks or benchmarks..Locate all wells within 100 feet.Locate where public water supply enters the building. 1d A p � Q i p I 3a'c" 3 3 F'O Q i 34'r" a 3� 3 33' TOXIN OF BARNSTABLE LOCATIONA.3� B SEWAGE # { VILLAGE ASSESSOR'S MAP 6� LOT sg :.INSTALLER'S NAME 6z PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY /5 LEACHING PAC ILITY:(typeo)5-0�y_ r acts (size) ,53)(13 X Z NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR,OWNER o F DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:11_6-Q 1 VARIANCE GRANTED: Yes No ti ` �'`'� r � �3p ���� �� � � 5�� 3a �' . I� - F,,., 4 �,�� �.-- .._ _ Y.._ i No. O '�, f ` Fee J THE,COMMONWEALTH OF M,ASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0pprication for �Digaal bpttem Cott.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. a 3 y 0.t -e C i24 Owner's Name,Address and Tel.No. �f D Sty. /Jo rt�- Tc'n/j y _S �yri�a Assessor's Map/Parcel //(0 _ O / Installer's Name,A*&W TBI,ikco (O Designer's Name,Address and Tel.No. S50 Main Street W. Yarmctgf, Type of Building: Dwelling No.of Bedrooms L of Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4/4/6 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /,S'oo Type of S.A.S. Description of Soil jW ecP. cf Nature of Repairs or Alterations(Answer when applicable) L h 144 (SD O S X 3 S-0 0 a& /e a c h 0 AAA be- / Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. / Signed V i/ � -t Date /A.7•I Application Approved by Dated^ �T Application Disapproved for th following reasons Permit No. 2 gL Date Issued 1) ��g No. / / O �,.� 0 -t l Fee +� / T.H -COMMONWEALT4QF_,NASSACHUS`�` ,•9`�' Entered in computer: �- +. �.. .. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS f r a Z,pplication for Mizpogar *proem Conmfuction Permit Application for a Permit to Construct( )Repair( )Upgrade( i )Abandon( ) O Complete System ❑Individual Components t= Location Address or Lot No., d 3 f L,e r / Qwnner's Name,Address and Tel.No. /TUnf Te pzi1)y S Cyr iCPo G t�. a Assessor's Map/Parcel �n `.1 5 V(� 7 Installer's Name,Add*&nffeCANCO Designer's Name,Address and Tel.No. 350 Main Street , W. Yarmouth, MA 02673 Type of Building:;, Dwelling No.of Bedrooms �t'D of Size " sq.ft. . '�Garbage Grinder( ) Other Type of Building No. of Persons " -' Showers( ) Cafeteria( ) Other Fixtures Design Flow 411-10 gallons per day.^,Calculated daily flow gallons. Plan Date Number of sheets 1' Revision Date l Title Size of Septic Tank Type of S.A.S. Description of Soil t Nature of Repairs or Alterations(Answer when applicable) Z/r (A/(`' I / SU o Sr ( `' >f o 3 s D o 664 her r y ' Date last inspected:, i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. 4, i Signed Ji � -�-t Date /.t •7.9 Application Approved by t Date ( 2 Q' Application Disapproved for th followmg reasons l � . Permit No if 1� Date Issued (a- k--9� ------------------------------— ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( 4.-rUpgraded Abandoned( )by at o?3 e.1 e.►" i2c� U 5 f U r1I f 5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2L-dated 12- 7 Installer _ Designer The issuance of this permit shall not be co'nstr'ued as a guarantee that the syste will fu t tion as des}•�g�ne..d-.yy.. Date b :L0I Inspector � k . �4M'(�'� ---------------------------------------- No. �` Fee � O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Xkgoar *p!5tem Conztruction Permit Permission is hereby granted to Construct( )Repair( grade( )Abandon( ) System located at ,2341 t�� �c�- i2G�. O�fet �.%fC y n :f- s 3 and as described in the above Application for Disposal System.Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by l m) /5�a 0 ,3 • 3 t).W • �( l 1/6/99 NOTICE: This Form Is To Be Used For the.Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 44ki mom, hereby certify that the application for disposal works construction permit signed by me dated /a • �'- F 9 concerning the property located at a 3 Y /�G rl,Ct r ���p !"D'S - u n,f S meets all of the following criteria: The failed.system is connected to a residential dwelling only. There are'no commercial or business uses associated with the dwelling. , The soil is classified as CLASS I and the percolation rate is less than or equal to.5.minutes per inch. There are no wetlands within 100 feet of the proposed septic system / There are no private wells within.150.feet of the proposed septic system t f / There is no increase in flow and/or change in use proposed s / There are no variances requested or needed. / The bottom of the proposed leaching facility will not be located less than five feet above the madmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor . method when applicable] r P r • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above.the maximum adjusted � groundwater table elevation, k Please complete the following: w A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment. 1. DIFFERENCE BETWEEN A and B �i i SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder.cert <a �l L4 n r tJw 5 ( ........... 1 .:r--� },�;..�•r�.,.. Y�� � ��+y£. f�'�a� as�Cb��F J"S ash 3..T y.+�:�r-� s � ... `nt��R�� e sc.i J'k�'^'s,,�` r��'-k�$aN � �'Y VILLAGE &5/,C elllUe� S� y � ASSESSOR'S MAP Sz-LOT INSTALLER'S NAME'Si PHONE NO A & B CANCO 775 6264 .SEPTIC TANK CAPACITY LEACHING FACILITY•(type ' J1'_ �m��V_S. (size) 33 X(3)( 2 NO OF BEDROOMS-y (z'� PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER la7U� t , DATE PERMIT ISSUED = DATE /l $k COMPLIANCE ISSUED D VARIANCE GRANTED Yes L o r 1 ar , ` c r • ti 1 I 3 y 32 F d - �c� ;!ts 2s: TOWN OF BARNSTABLE �L LOCATION_ �/�fI��C�� �D �,��"T SEWAGE # -Sol? VILLAGE 0- 5*X Ul LC L ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(typer'3�y (size) 33 X 13 NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ��/� � DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No '.9 . � � _ __ :� 4. � �� � ,: ~; � -' r , � ... No. '' `",Y„ ,._ Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. V/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpprication for Miquar 6pgtem Congtruction Permit Application for a Permit to Construct( )Repair(✓Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 0,3 / �.r�er (� , O ner's Nam Address and Tel�9 A �Slrrv�lleunf /tmpyrc�0 /rfs-r. Assessor's Map/Parcel ///_ 06/ Uf f 3. e Installer's Name,AddreA WK LIOANCO Designer's Name,Address and Tel.No. 350 Main Street W. Yarmouth MA 02673 /1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow yy0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / S�QQ n Type of S.A.S. Description of Soil {'h�Ll' U,4yle Nature of Repairs or Alterations(Answer wh e applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o Hea Signed 41 Date /al• Application Approved by44 Date�? r' Application Disapproved for Ye following reasons Permit No. l`/$ �,_7 Date Issued -­FeeU .r THE COMMONWEALTH OF MASSACHUSETTSEntered in computer: Yes PUBLIC HEALTH DIVISION - TOWN,OF BARNSTABLE., MASSACHUSETTS Y Application for Dioogal *pgtem Con!9truction Permit = Application for a Permit to Construct( )Repair( 14pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a 3 y e.l' (�� Owner's NamiAddress and TeL // �S CU+{IQ f�Unf /C✓v,nYl. CGti�G�0 Assessor's Map/Parcel /_ 0 v I 1 3_ V Installer's Name,AddresAArg NCANCO Designer's Name,, ddress and Tel.No. 350 Main Street W.Yarmouth, MA 02673 Type of Building: L' � ft. �, , Dwelling No.of Bedrooms7 4 Lot Size sq. . Ga bage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures „'S V Design Flow `/`/0 gallons per day. Calculated daily flow �. gallons. Plan Date Number of sheets Revision Date Title e, Size of Septic Tank / ��00 Type of S.A.S. Description of Soil /'1?{'�• �Av1GQ Nature of Repairs or Alterations(Answer whe `apo'li�cable) _2ell/A// / V UO C9,4 t . Date last inspected: 1 � Agreement: The undersigned agrees to ensure'the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Hea Signed Date io )- 9 9 Application Approved by Date Application Disapproved for Ye following reasons - '"Permit No. f ST 2 '7 Date Issued --- ------------------- --- ----'------ THE COMMONWEALTH OF MAS$ACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( 1_4pgraded( ), Abandoned( )b /�•CJC U , at c-) �� ct r�r r i2�eC) V//% U + 3+Y has beeri>constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q- g 2. dated I - - Installer Designer The issuance o thif permit shall not be construed as a guarantee that the syst ill f�nction as designed. I Date 2v� Inspector n 6W• ---------------------------------------- NO. / �j a Fee S i] THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi5po5al 6potem Construction Permit Permission is hereby granted to Cons�ruct )Repair( Upgrade( )Abandon( ) System located at .3 9 01 f C' i f /2 eo,�, U A f'fi 3- `( and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by WILT ' S-i�ti'L� - I - -- - --.. - --,---- - � --- ,;;:: `t t M l .` i., ' -.1, ...-�.. 4 y. ;smit l,,,. n . .­ " I -. *,..�`.........I; .".. " - ,�- �"...- -,- : ... : : 4� ; 71.-�tIvi�'`,,-". , ..�j�'�.........,4�.�. - : :1T- ,1...........I�- %, -, ..,-�..1l .�..-, , .- ., I ;-, `— --i..�� .'1. a . � , T. � -Z ),, �- , i � � . LOCATION2�A�, to e A SEWAGE # 1 VILLAGE . r /L -- ASSESSOR'S S MAP_ ,, - I M. .:.1 . , . � - 1. - ". - -I; , - � --,--'"�- , .-I,- ..P' -t.- *- � l- ���,,,,, I .-- ;-".. - - .:.,, � - INSTALLER'S,NAME ,PHONE NO A &,B 'CANQ0 � 77r"6264 - � ��- I. ,-� , I*, I. .,.., ; � - - �., !. , : : *. ,-. -�� - - r ..�. I V - .. , , �- I I , �II .. -. . -- - ---- - SEPTIC TANK,CAPACITY /5 r,*/ LEACHING FACILITY.(type vos (d *) 33: ( 7 2 isii, pr4ii i,t,f !?,iat i,,i Ll T,, I..l �, t �, NO OF'-BEDROOMS . PRIVATE,'WELL�OR:TUBU C�WATAl . BUILDER OR.OWNER 3 � T)�,r17 . .: . � � !! lFI MATE PER T ISS ED ,- _"X'Y3 ;! .. :, ' DATE COMPLIANCEl18St /7 . O/ ) ' V : ��i � y ,? ? � , No �- ! A 4 ! . t .. .; ,1 J. : j,f. ;4 --` Y n.y ' F I, * " N'�'�Ai .— , � ;' -" 1 . o . 1 .. ' "1 . .... I i . I . p- - - . II .. I 0 , 1- .I r 7 . [. I I. . z I . . . I . . , . . , :,- . 'I- I . . . . ., -..— . - =: - . , -. �-,-7---,-. ------­�:---- .. t " ., ---- - -� �7 I — !�-�i-1 , , .. . . . . I I I .� . . . � . . I . i - 4m 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION-OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works- , construction permit signed by me dated concerning the . •/ ; R � r property located a`t a 3 FAG•(4r r PS:` S E ` yn �- 3—�� meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. s • There are no wetlands within 100 feet of the proposed septic system /. There are no private wells within 150 feet of the proposed septic system / There is no increase in flow and/or change in use proposed There are no variances requested or needed. j- The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] - If the S.A.S.will be located with 250 feet of any vegetated wetlands the bottom of the proposed Y g p posed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation 6, +the MAX. High G.W. Adjustment.L DIFFERENCE BETWEEN A and B 0201 SIGNED I DATE: �01 • • 4'g [Sketch proposed plan of system on back]. q:health folder:cert i 3 �- �• ra t. 0,0F S ar D gl O O LEONRR J23 y.:93- yO:CB .. Q 00 JEunS/E 2e:EH.. 77 Q. e ".49_\ i P.B.C^�'e. b L� LtB9., 'BLOC �, V q ! ST. ,39 �. 1... 9/.¢O .. ; a 0 uN/T'E.._O� ll Q v 3' N BOe _—���11 01 0 _ee.eo... Q •e �P R •.�-600E �Iq 1 --' �� 2 --GOCAT/ON MqF±. 2 3/.4J g Y V 11 11 eeV UN/TS/F� � (� lb/ to 1 2 4oJ ee.oB I _ 1 0m0 1� CpMMJN- RPEP .. 11 1\ 1/.LB_J i--• C'I w 3Pso. 847: � '. •� O _—_�04 ' / i� y6/E��d P Ep __ _ •11 M� PRER 4J� � ice.COMMON 11 N zB .F /; 6.3PBN/T-4 p d l OEEO RFFFRFNC6-: P lj7,B7 �I I V .Bo K:/i94 PgC6'4T4 - I L1�(` 4BB � O..BLOSBe.oa i I ° `C e.00 I A oo I I. RQER 1 11, n 4d9.'i•9 x/ K1.. I �:.G.OMMON !. 1 N B/' 1'q I I: � S CER%FY THAT THE PROPERTY n. 1 1�p I I.- 1 y/. L/NES 3/.OWN ON TN/S PL qN:O.PE THE ,C Z ;41 14� I 1 6B , FP RNO THE G/NES OF TN6 STREETS ANO 1 I ._ 239• 'WAYS s NN qqE HOSE OF Pt/BG/C - 1 Oq PR/VipTE S7REETS OR W.QYS.!iP6gOY 1 _¢8.00 ESTgBUSNEO ANO TNgT NO NEW L/NES ' ' � NVE FOR O/V%/ON O/'EX/ST/NG O NERSN/P OR FOR NEW WqY 9/.80 O//.FPI :... • 1 v ,SECONp �° s CEgT Fv rNgr TNLr.eGa wqs M GE PL A/V. OF L/4/VO . 10 W/TN GgNO COURT S7gNOAROS OF gCCUgqCY - q O TNgr r E Po/Nre SNowN+ 'LOCFJTEO /N to of B•xisr++N ��'p,� BRR/VSTf76LE,osrE-.pviLLE,M/7SS. PREPggEO FOR ow.iP _ _ BENL/E7/N/N /A/VESTME7VTS,/NC. S T FY TN/>T TN/ �eS C ATiFY TNgT TN/S.'•Y qN CONaORwf9 Q qN0 q CURq 6LY 06P/CTS THE GOCgT/ON TO THE R(/LES NO REQU<q%ONS OF OCT/B//9T 9 �� qN0 O/HENS/ONS OF THE BU/LO/NCS/7S THE B RNS7ABL EC/STQ7�FLM'FOJ _ PG qiy O'T9/O/O /LF NO'/SO Bq B/l/GT-A'O FULLY L/STS T E t/N/T CON- �(E/ F \V.00r/O+/9>9 iO- CgF6 O•/StgNOS S//RYEY/NC+/NC. O Co •?O.BOX 9S4 ' TEgT/CKET+MASS. ' YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain they necessary signatures on this form at 200 Main St., Hyannis. f Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get he Bpsiness at is b required by law. DATE: �:. I / Fill in e:n - APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDR SS: ��` r _�r rC� c'C� 0 �ry l C�5�5 f Y TELEPHONE # Home Telephone Number 7 7`f ��fQ `'11 y NAME OF CORPORATION, F� s / �� P NAME OF NEW BUSINESS C SAC S�.GN T1FPE OF BUSINESS:C . c¢.;.. '✓.rCz S. l� " iG% v . IS THIS A HOMEI,OCCUPATION� ADORES OF BUSINESS Z3.'<( a<I�e zf t v,/fie. MAP PARCEL NUMBER Assassin When starting anew business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has bee f rmed of the per �ra iremen t t pertain to this type of business. rize Signature COMMENTS: ,c 3. CONSUMER AFFAIRS ICE ING AUTHORITY) This individual h e f the licensin r qui e en that pertain to this type of business. Authorizere* COMMENTS: Oi L'O CAT ION S W A G E ' PE llUrT NO. VILLAGE INSTA LE 'S gAME AOORESS 6 U I-L D E R OR OWNER Con' =f- i DATE PERMIT ISSUED _ �_� OAT E COMPLIANCE ISSUED _ � � 'oo,� t F S LO C A T IO SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 4-1 �w Ack �'f fL/lam/Z i iS s s THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............. ...............----------..OF....................................... .AliptirFa#ion for Uhipos al Works Tnnstrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: •.�d Loca Address or Lot No. 12.1 W O er Address (1 - �. Installer Address Q Type of Building /; Size Lot............................Sq. feet Dwelling-L;to. of Bedrooms.._.0.................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons........_.`�_............. Showers Cafeteria ( ) Other fixtures ................ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-_-.-_--_-•-__ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No ............. Diameter.................... Depth below inlet.................... 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........................ fr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 --••----••-•---••----•---•---------------------•....------.......------...------•----••----•--------........................................................ 0 Description of Soil......................... x P _ w .................... .....-•--------••------. -- x --•--------------------------•-----.....---•----••--•--•••-------------------•-----•-------•-----•---•----•-----•-----•--••---------......................... ------------•-ep ...........----- U Nature of Rairs or Alterations—Answer when aplicable____ o __jam S_�7j/_.._ ®©0.. > '�.(w= .lr��_� ._._. ...... iT.(�1 1 �. _ice.. -•..To------ Agiieement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIU 5 of the State Sanitary Code— The u igned further agrees not to place the system in operation until a Certificate of Compliance has i u boar �f health. Signe .-- ...... ...................... ate - ApplicationApproved By........... -- -•••-- -- -- --•..... . ... ........................... ....... � —AZ Date Application Disapproved for th following reasons------------------------------------------------------------------------------------------------------------•---- -•-------------------------------•---------------------------.....------......-------------------------••-----------•.......---------•-------•----------••--------•-•--••----•---•----•------•....----- e Date Permit No.....�%7 .. �` �. S •---•------ -... �------------•---•---•--- Issued--------�•-�=-�---s-�--------------•-•-•--- Date - - -----_-- ----_-- -------- - - - - - _�- _-- - --- ------ --- - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... ..........•----...OF...................................... Appliratiott fox, Dispooal Works Tonitrurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal, System at Y L/mot Loc 'o -Address or Lot No. ------- .......... •-- Address __---____- ............... .................................................................................................. Installer Address Type of Building rl Size Lot............................Sq. feet �-, DwellingNo. of Bedrooms.___ Z Other Attic ( ) Garbage Grinder Other—Type of Building ............................ No. of ersons........ ._ Showers (/ ) — Cafeteria ( ) A4 YP g P '...... d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width.........._..... Diameter-------......... Depth................ x Disposal Trench—No, .................... Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No-----------------_-- Diameter...................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ............................................................................................................................................................ 0 Description of Soil................................•.. x c, x ............................................................................................................---•- ---------. U Nature of Repairs o Alterations—Answer when ,Rplicable Q.../ ,� � ',�� � 'A'j :�� .k s r',-._-- Ag eement. The undersigned agrees to install the-aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITA LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha b •""�`•-suedby le board'<of health. f . N. ......__. Signer n : _ .....,, : ' _ ... ..............�------------------------•- - � -•--- "� t A lication Approved B ate PP PP Y /fit' �. <ti--- �'+� .:...: .........•------.......__... Date Application Disapproved for th following reasons:.......................... . :. Date Permit No.._._S?_�q 5."__a�.11------------------------ IssuecL....... _.............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................................ ......OF..................................................................................... %-Urtifiratr of (911ntpliancr THIS IS TO�ER-�yT,�I.FY, That the Individual Sewage Disposal System constructed ( ) or Repaired/ ) by---•----...... � ' --------C4A ------------ -------------------------------------------------------------•--•---------.._..--- 4 ... Installer 1 F✓ - at. - �...................... has,been installed in accordance with the provisions of TI T LF 5 of The State Sanitary Code as described in the application for.Disposal Works Construction Permit No.___--T_ "�_A!!�..._...... da.ted___.�__- . __--_. ',„►�' ............... r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSYRUEDS A GUARANTEE THAT THE SYSTEM WILL FU CTIO SATISFACTORY. DATE._..-----•....•."(.....�..� _:.... .--•-- ••----• Inspector._-••-••--.-- : • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................OF...........................---...........----•------.......... No......... ........... FEE................... �i��ro��tl ork �on�trttr�ion rrinit j`Permission is hereby granted C !----•--r----------------.•---•---•-- -------------- ..----•--- to Construct ( ) orNRepair,f� ) an Individual Sewage Disposal. System atNo. "..==....: ��. ------- ------------------------------------------•--•-------------------------•-•--_.._....._ Y ..... Street _ as shown on the application for Disposal Works Construction Permit NoVi _01. Dated....... ...._ ` ........... ....................... -.I-.......................................................... Board of Health DATE ---------•••-•--••......--•--• - FORM 1255 A. M. SULKIN, INC.. BOSTON - 3 5;7 No.. 2:... Fxs.1 5..00.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....................Town...........OF.......Barxmt;1 ble........................................................ Appliratinn for BhgpuaFal Works Tnnitrnrtiun "Prr ni# Application is hereby.made for a Permit to Construct ( ) or Repair .(x ) an Individual Sewage Disposal System at: 2 Parker Rd._- tervilleMA 02655 -- �:-- s I... •!-l c`_ V d.( . ........cp-'-.......-............................... - Y , Location-Address o Lot o. y 88 West Main Street 1-g annis MA 02601 Centerville__Com n ---9•--•-•-••••••-•-•--•----•............................•-.......... .........----•••-- Owner Address a �`•••' �, _ L. .�.�............ .. .� .......- ...................... . .. .... . ..... st..aller Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons...... ................... Showers ( ) — Cafeteria ( ) Other fixtures -------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank=Liquid capacity............gallons Length................ Width................ Diameter...---.......... Depth................ 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 ( ) ~' Percolation Test Results Performed by.......... ............................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water..--.................--. Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water..........:............. a' -----------------------------------------•----------------..........---...................---.....--......................................................... 0 Description of Soil...SaAd............. U ..............................................••••••--••••••••-•-•-•-••-••---•-•••---........---•-.......-••••-......--•--------•••••••-•-•----•••••••.........••-•......-•-•--•-•--•-•••••---•--••---- W .. UNature of Repairs or Alterations—Answer hen applicable.installation--of a---1.t 000 gallon pre-cast.. stone packed leach pit (overflow . ` ---•---•--.....----•---------------------------------------------------------------------------------•-------_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with . the provisions of T1TY-E 5 of the State Sanitary Code— The undersigned furth , agrees not to place the system in operation until a Certificate of Compliance has been issui d by the board of he .1 D0 Signed..... . 4,1� 7/ 8�82 • //Dt Application Approved By............ .'�. -------•---•7/- t S2 ��..----------------•-----------------•--•----------•••.................. Date Application Disapproved for the following reasons:--.. --------------------------•------------------------------•-----------------•------------------...•••....... r Date Permit No...t..................................................... Issued.---./•••- --. Date 2....j_ Fps ... ..00........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........L own.............0 F......Par.r-stab.le......................................................... Appliration for Disposal Works Tonstrurtiun rumit Application is hereby made for a Permit to Construct ( ) or Repair � ) an Individual Sewage Disposal System at: 1 23.. Darker 'Rd., 0sterville, �'A 02655 .a- � .S! 11.E Q' . .............•.. .....4 _--------_--..., - - e. ................5 .r- r Location-Address r No. Centerville Company FF9 ingest Fain Streef,LoVknnis, mA 02601 -- _...............................•...--•-------•.........----•-......_.... ...............••..._....-- -• ......---•--•••-••-•-•••-•-•--....................... Owner - Address . .... _ s 4.V ....._.....1 ........................... .__....Add ...._...__._........ .... � nstaller � ress Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) 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 ( ) Percolation Test Results Performed by........................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•-----------------------------------------------------------•-.......-••---...................................................................----.------ ODescription of Soil..;aW.----------•--------------•----....................---•-------......----------------------------....-----....------------------------I--------•------------ x W U N ture of Re a' s or Alteration —Answer when applicabl�nstallation..of-.a. 1_,000 gallon-pie-CaBt_,,_. shone packek leach pit overflow) . --------•---------------------------------------•-•----------------•----------------........-----------........------------------------------....---------------------------------.................•••-- Agreement: The 5ndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTf,,�. 5 of the State Sanitary Code—The undersigned furtl: agrees,not to place the system in operation until a Certificate of Compliance has bee/nfi/ssiled by the board of he ft . �' = - L n7 �* / Signed-- ---------------• �°-'fit..' 't- ---•------....----•-�•� -'�----�-!//---,n�,�•-•-------- Application Approved BY -- e......•--•--•-•---........-••-••••--••.....................•-•--•••--•-•- -•-•,.....7l--- 1�-2--------•--- I/ -�`� Date Application Disapproved for the following reasons--------------------------------------------------------•------------------------•----•-••---••-•......•--.•-•-- -•-•-•••-••--••...............•••--•--•-...._..---•••••••--...-••••--••••...-•--••......--..........••...•-•••••••-••--.....----•••---•--•-•---••--•-------•-•••••-•----•-•----•••......•-••----•----•-- Date Permit No.......82-_......-.?.�7-7•---------•-•-----...... Issued-V 8/82 to Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 own Barnstable ..........................................OF.................................................I................................... Intifiratr of Ti x THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired { } by.......A._&..B CessTool..Sery C�.,...�2R__.�?�.whops...Texr&ce.,.--HvaTanis,..TaA.....02.6al...................................... Installer Farker Rd.� Qsteryill®_e.. !A QS__-_..Gex�texvills.C �Y-----------------------------------•----------------------- has been installed in accordance with the provisions of a -h; ` of The State Sanitary Coc�/� ribed in the application for-Disposal Works Construction Permit No................. ..... d-ated..................' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL� pVF1ION SATISFACTORY. / piss//S22 , DATE............................................................................._.. Inspector.......... .-----------------•-•---•---------•------.-.----•------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF'-HEALTH ° own lam stable rn -�2- 3 ......................OF.................................................. $5.00 No. FEE........................ Disposal Workv Tnns#rnrtion rrntit Permission is hereby granted......................A-A3..CP.ssuQol.Se-vice--•---........--------.....................................--•----• to CO u kdr°tc .epa�s err i l 'd'K u�2 j e 8e$ erV jjJe C Ompa iy atNo.................................--............................................................................................................................................................ Street '32 C< as shown on the application for Disposal Works Construction Permit No......___'f 7__ Dated.._7�..`-� 2--.- // 8/82 Board of Heal' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS