HomeMy WebLinkAbout0129 PARSLEY LANE - Health 129 PARSLEY LANE
Osterville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ 1. Subsurface Sewage Disposal System Form Not for Voluntary Assessments
129 Parsley Way h�a
LJ� <iTW
Property Address j
Thomas Henningan CC1
Owner Owner's Na
mJ�
information is Osterville r/ Ma 02655 7-26-19
required for every =-
page. City/Town State Zip Code Date of Inspection,.-y
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 67# Iqo v--
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
f (508)477-0653 S113747
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
m"1=14:
Brett Hickey <>. a,p,,�,�,,,; 7-26-19
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 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
• S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L 129 Parsley Way
u
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
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:,r
❑■ 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:
The system was in working order at the time of inspection.
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 complyingse tic tank as approved by the Board of
P 9 P P
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
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,v
129 Parsley Way
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cant.):
❑ 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
�n Title 5 Official Inspection Form
±= r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
�u
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
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 1.00 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
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Q 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
�n Title 5 Official Inspection Form
�= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
v
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
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
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high groundwater elevation.
❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.] E
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ El 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 C.4.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 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
f
Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Parsley
129
•� Y Way
V, Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to an question iri`Section C.5 the system is considered a significant
Y Y any Y 9
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
Q ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ E Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ O 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)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ a 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.
❑ a 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
r Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
129 Parsley Way
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4 -4
Number of bedrooms(design): Number of bedrooms(actual):
440/GPD
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes [j] No
Does residence have a water treatment unit? ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes H No
Seasonal use?' ❑ Yes [g No
See below
Water meter readings, if available (last 2 years usage(gpd)):
Detail
***2018- 101,000gallons 2017- 81,000gallons***
Sump pump? ❑ Yes M No
current
Last date of occupancy: Date
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P Y rY
129 Parsley Way
�V
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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: Owner- last pumped 2 years ago
Was system pumped as part of the inspection? ❑■ Yes ❑ No
1500
If yes, volume pumped: gallons
How was quantity pumped determined? tank size
Reason for pumping: maintenance after inspection
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
�n l Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
L Property Address
Thomas Henningan
Owner Owner's Name
information is required for every Osterville Ma 02655 7-26-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 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:
2013
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
V5rr
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
l5ins .doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
P P 9 P Y 9
lil '
c Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
°l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
u
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
501
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
1
Dimensions: 500gallons
711
Sludge depth:
2911
Distance from top of sludge to bottom of outlet tee or baffle
311
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
1311
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank was pumped after
for maintenance.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c Commonwealth of Massachusetts
,/p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
V
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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):
NA
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
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
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.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0°
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.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
V�
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
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.):
NA
* 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:
(3)500 gallon chambers
El 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
u
Property Address
Thomas,Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
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 SAS was in working order at the time of inspection. Chambers were dry when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v—
129 Parsley Way
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
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
�d Title 5 Official Inspection Form
Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f;
129 Parsley Way
V
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
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:
❑M hand-sketch in the area below
❑ drawing attached separately
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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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
V�
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
❑E Surface water
Check cellar
c
■❑ Shallow wells
Estimated depth to high ground water: NoGW@12'feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
7-29-13
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:
A plan on file at the local Board of Health was used to determine high groundwater.
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
C Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
129 Parsley Way
Property Address
Thomas Henningan
Owner Owner's Name
information is Osterville Ma 02655 7-26-19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
■❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑� D. System Information:
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
i
Town of B
arnstable r#
Department of Regulatory services
SAMMBL Public Health Division
Hate
200 Main Street,Hyannis MA 02601 '
Date Scheduled
o fine
Fee Pd. V D
Soil`Su i abiii Assess
�' Assessment for Se e D s l
Perforated By. �� �+� F o
Witnessed By: p
LOCATION& GENERAL INFO l
n; Location Address,J� INFORMATION
� ���.�L � Owner's Name
Address
Assessor's Map/Parcel:��z�',O,16- r
. \ : Engineer's Nam
REPAIR
NEW CONSTRUCTION ��
1� Telephone# _0000�/
Land Use:
` Slopes(%) Surface Stones
Distances from Open Water Body ftM pdsible Wet'Area
-ft Drinking Water Well ft
Drainage Way ft Property line' ;
-----__ft Other` ft
SKETCH:(Street name,:dimensiotis of lot,exact locations of test holes&perc tests;locate wetlandsn proximity to holes)
t i
CD
. , �L�itP�1[�t�j (,!"� k �:... •cam
1;j R,rl IdpA � rl , CDs ""Tt
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wig_ M
+' Parent material(geologic) `� t
Depth to Bedrock-----------------
Depth to Groundwater. Standing Water in Hole:
Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMNATION FOR SEASONAL III WATER TABLE' Method Used:
Depth Observed standing in obs.hole: _
Depth to weepingfrom side of obs Reading .'hole: in. Depth to sell mt►ttles:
Index Well# in, Groundwater Adjustment in ln,ng Date: , index Well level Ad,thCtor
1 — Adj.6'roujidwate,Leve1,
Observation PERCOLATION TEST Date m� ,time
Hole# i
Time at V, V
Depth of Perc VC
Time at,6Start Pre-soak Time @ ,_-._.--Tim (9„-6„)'vt
End Pre-soak
Rate Min llnch /
Site Suitability Assessment:"Site Passed" Site Failed:
Additional Testing Needed YIN)
t
Public Health Division`
Original: } Observation Holt;Data To Be:.Completed on Back
If percolation test is to be conducted within 100'of wetland,you must first notify the !Barnstable Conservation Division at least one(1)week prior to beginning.
Q:LSEPTICIPERCFORM.DOC
I
Y i
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DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling " (Structure,Stones,Boulders.
Consistency,% ravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color ' Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. .
Consistency,% ray
r
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, o Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consist n
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year boundary No r' Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervi usAiperial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of na urally occurring pery ous material? _
Certification
I certify that on �� (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Protection a d that the above analysis was performed by me consistent with .
the required t ' ,exper' a x ri ceAdescribed in 3 10 CMR 15.017 'I
Signature
Date
Q:\SEpnC\PERCFORM.DOC
i
i
TOWN OF BARNSTABLE
LOCATION 9 If40 1e)' Z--" SEWAGE# S ®Z
VILLAGE ASSESSOR'S MAP.&PARCEL
INSTALLER'S NAME&PHONE NO.
ff SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)T�
NO.OF BEDROOMS
OWNER
PERMIT DATE: c' 9" COMPLIANCE DATE:
Separation Distance Between the: e
r
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on,
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
eAo
` n O
S- � - a7
7 -
7-• tLp
TOWN OF BARNSTABLE Fruo.,
1:0(,ATION Ar P a e- SEWAGE # 'ems
VILLAGE' Ocilt ui III... ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
Mn�n a UJQr��ov
LEACHING FACILITY: (type) 3 wf P"1S ( ize)
NO. OF BEDROOMS
BUILDER OR OWNER ��'S
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site gr within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 3W feet of leaching facility) Feet
I
Furnished by `y
Swine Ties:
Garage Exist House
(3 Bedroom) A- -Cesspool#1 —23.5'
B—Cesspool#1 —335'
A B A- -Cesspool#2—50.5'
B—Cesspool#2—21.5'
O O O
Cesspool#1 Cesspool#2 Cesspool#3
Parsley Lane
r
No. � Fee
HE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
n PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
\l 01pplitation for Disposal .4pstem Construction permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
i
Location Address or Lot No./D9,5'OZJ'ltY Owner's Name,Addreys,and Tel.N .
Assessor'sMap/Parcel /��' 4
4/6 p` kAIY,'G
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: L
Dwelling No.of Bedrooms T Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No t.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) S�%G' gpd Design flow provided �J gpd
Plan Date ">—.;z Number of sheets y Rvision Date
Title
Size of Septic Tank �So ��"� Type of S.A.S.
Description of Soil
Nature;of Repairs or Alterations(Answer when 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 Certificate of
Compliance has been issued b s Board of He
Date
Application Approved byym, Date
Application Disapproved by Date
for the following reasons
Permit No " Date Issued
- --- - - _ =
No. a
J t
Fee
C THE COMMONWEAL WOF MASSACHUSETTS -Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes m
O
01pp tatlon for MIsposal 6pstem Construction permit
A f
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./.:?9�jf4j%e f Owner's /Naammee..,, r' I
,Address,and Tel.N
Assessor's Ma /Parcel f
p o/�' OJy (ram-' V 16�f��
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
TI pe of Building:
Dwelling No.of Bedrooms T Lot-Size sq.ft. Garbage Grinder( )
Other i T e of Buildin yp g lj2°�.� Noi of Persons., Showers( ) Cafeteria( )
b 4!
Other Fixtures
Design Flow(min.required) gpd. . Design flow provided 5•* gpd
Plan Date Number of sheets / Revision Date
Title
Size of Septic Tank 4�r> 04 '40 J Type of S.A.S.
Description of Soil
' Nature of Repairs orAlterations(Answer when applicable) -Pee-
Date last inspected: f
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in y
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ,>�
Compliance has been issued b this Board of Hea
n1d )/] Date
Application Approved by Date
t
Application Disapproved by Date
for the following reasons f
eA
Permit No t "per Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by ZA;�?0
at f,� �' � '���/ .�-� O 1'T' has been co tyte,�n a,co Ace
with the provisions of Title 5 and the for Disposal System Construction Permit N ated
Installer l��drj ��OCU/�� Designer ,
#bedrooms Approved designflow Z gpd
The issuance of this permits not be c7[!6
st-ue"s a guarantee that the system nc'o as Jdesigned. G
Date Inspector 'All yzjj�,A
--------------------- - ------------- -------------------------------------------------------------------
No. � �y' Fee--��—
111 I THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstrm Construction permit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at 7-
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or s-Decial conditions.
Provided:Const ction 7SA7 completed within three years of the date of this permit.
Date / Approved by F
I
Town of Barnstable
t►+�rot, Regulatory Services
y� Thomas F.Geller,Director
s
NAM Public Health Division
Thomas McKean,Direcior
200 Main Street, Hyannis,MA 02601
Office: 508f 624 44 Fqc: -790-6304
Date: �' Sewage Permit# ` Assessor's Mapfrarcel
Installer&Designer Certification Form
Designer: DOUC7 � Installer:
Address: ^.r C�6 "/cU• G; -� Address:
On t�y� was issued a permit to install a
(date) (installer)
septic system at W. based on a design drawn by
jib (a dress)
1 i" q 41qbdated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &Local p� •'-tions, plan revision or
certified as-built by designer to follow. Stripout(if r?• acted and the soils
were found satisfactory. rttk OF MqS
DAVID
stal er's Signature) MASON n
No.1066 o aT f
`sT �
� 9
esi er s Signat7xrej
PLEASE RETURN TO BARNSTABLE PURL,,..
OF COMPLIANCE WILL NOT BE ISSUED UN i tL ts'u I ti 1 gIS r O M AND AS
BUILT CARD ARE RECEIVED BY THE 13AR,NSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAotflce formsWesipercertifation form.doc
S
\ COMMONWEALTH OF MASSACHUSETTS
F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTIO
oW ,
RECEIVED
J�v
RN
OCT 3 2002
TOWN O FBA NSTAB`E
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A I �
CERTIFICATION
Property Address: 129 Parsley Lane
Osterville,MA 02665
Owner's Name: Mr. Donald Ellis (�
Owner's Address: 129 Parsley Lane MAP
Osterville, MA 02665 w o '
Date of Inspection: 9/13/02 PARCEL
Name of Inspector: (please print) Mr.Carmen E.Shay ,OT -
Company Name: Shav Environmental Services,Inc.
Mailing Address: 34 Thatchers Lane
East Falmouth,MA 02536
Telephone Number: (508)-548-0796
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:
XX Passes
Conditionally Passes r S
Needs Further Evaluation by the Local Approving Authority, R E
Fails 1 . E.
Inspector's Signature: (—ZDate: 9/13/02
4.�
-9 NS?
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of He
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 i
authority.
Notes and Comments
3' effective depth available at time of inspection in Cesspool#1 and 6' in Cesspool#3. Cesspool#2 acting as a
septic tank. Evidence of liquid level being 12" higher in Cesspool#3.
****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 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 129 Parsley Lane
Osterville,MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all;of Section D
A. System Passes:
XX 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
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:
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 129 Parsley Lane
Osterville,MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
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:
T41. G 1nc—t;— 17— ail cnnnn 3
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Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 129 Parsley Lane
Osterville, MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
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 '/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 well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(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
_ — 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.
T;.io c it-t;- F- 4/1 cnnnn 4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 129 Parsley Lane
Osterville, MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
XX Pumping information was provided by the owner,occupant, or Board of Health
XX Were any of the system components pumped out in the previous two weeks?
XX _ Has the system received normal flows in the previous two week period?
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up?
XX _ Was the site inspected for signs of break out 9
XX _ Were all system components, excluding the SAS, located on site ?
XX _ 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?
XX _ 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
XX _ Existing information. For example,a plan at the Board of Health.
XX _ 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)]
T41. 5
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 129 Parsley Lane
Osterville, MA
Owner: Mr.Donald Ellis
Date of Inspection: 9/13/02
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: None
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):_
Seasonal use: (yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd): 2000-58,000 gallons
Sump pump(yes or no): No 2001-54,000 gallons
Last date of occupancy: Currently occupied
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
Pumping Records
Source of information: None Available
Was system pumped as part of the inspection(yes or 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
XX 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):
I Approximate age of all components,date installed(if known)and source of information:
1960's-per Owner Records
Were sewage odors detected when arriving at the site(yes or no): No
Titio ci')Ann 6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 129 Parsley Lane
Osterville,MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
BUILDING SEWER(locate on site plan)
Depth below grade: 24"
Materials of construction: cast iron XX 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANK: (locate on site plan).
Depth below grade:
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 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: _(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from t'op 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.):
Trtlo 7
r
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 129 Parsley Lane
Osterville, MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
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/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: Not Present (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: (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.):
Titles nnn 8
r
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 129 Parsley Lane
Osterville, MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_(Pit#1 =Precaste 6' diam. x 5' short pit) (Pit#2=4.5' x 6' diam. block pit)
leaching chambers,number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
XX overflow cesspool,number: 2
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.): _
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: #1 is 6' diam x 6' deep,#2 is 6' diam by 6' deep is 6' diam by 6' deep.
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No
evidence of hydraulic failure ponding damp soil or stressed vegetation. Excavated covers and inspected
cesspools— 3'effective depth available in #1 and 6' in #3. No evidence of past hydraulic Failure noted,
Cesspool #2 is acting as a septic tank and is overflowing into both overflow cesspools. Liquid level has been
12" higher than at time of inspection in cesspool#3.
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.):
9
cilnnn
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 129 Parsley Lane
Osterville,MA
Owner: Mr. Donald Ellis
Date of Inspection: 9/13/02
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.
Swine Ties:
Garage Exist House
(3 Bedroom) A- -Cesspool#1 —23.5'
B—Cesspool#1 —335'
A B A= -Cesspool#2-50.5'
B—Cesspool#2—21.5'
0 0
Cesspool#1 Cesspool#2 Cesspool#3
a
Parsley Lane
Tales G Tncnart nn l:nrm �iT�i�nnn 10
Page I I of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 129 Parsley Lane
Osterville,MA
Owner: Mr.Donald Ellis
Date of Inspection: 9/13/02
SITE EXAM
Slope
Surface water - '/Z mile
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 13 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:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Quadrangle of USGS Map-No evidence of any liquid in cesspool#3 which is 9 feet to bottom
from grade.
Per Barnstable GIS:
Elev. of Ground=53Feet
Elev.Of Groundwater=5 Feet
Elev. Of Bottom of Leach Pit=44Feet
Therefore: 44—9A =34.9 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well MIW 129: 4.1 feet
Adjusted Groundwater Separation= 5' +4.P =9.1' feet
(Refer to attached work sheet)
Grade= Elev. 53 feet
Cesspools 91 and#3
Bottom of Leach Pit= Elev.44 feet
Cesspool #2 Acting as Tank
Adj. Groundwater= Elev. 9.1 Feet
TItIo C Incna tinn Fnrrr+ �n Ci�nnn 11
' II
Permit Number: Date:
Completed by:
I
I I
HIGH GROUNDWATER LEVEL COMPUTATION
I
i Q
Site Location: '� 1 S�Q� l,— (1 Lot No.
I
Owner: �pe��(� �� Address: 'S {t kF
Contractor: �A`Z��11C Address:���.n�m���C7�
Notes:
i
STEP I Measure depth to water table
I
tonearest 1/10 h. ............................................................................... Date 5
i � month ay/ywr
I
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
i site and determine:
OAppropriate index well...................................................I lil
OWater-level range zone ..................................................... I
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to S oa
water level for index well ..........................
.
mon h yqr
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A),current depth
to water level for index well (STEP 3),
and water level zone (STEP 2B) d -
determine water-level adjustment ..........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
i
from measured depth to water —
level at site (STEP 1) I •�J
It
i
I
i
Cape Cod Commission: USGS Well Data - August 2002 Page J of 2
United States Geological Survey
Observation Wells
As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission
publishes monthly groundwater data gathered by its Water Resources Office.
The water level measurements shown below are taken monthly from United States Geological Survey i
(USGS) observation wells and compiled during the last week of each month. They are published as soon
as possible thereafter.
Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water
Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to
predict high groundwater levels.
For your convenience, we've also provided links to USGS national and state data. See the last column in
the table and the footnotes below.
For further information, please contact H-Ydrologist Gabrielle._,B_elfit at the Commission offices (508-362-
3828).
i
August 2002
IJSGS Site
Water Record Record Departure from Numberl,
Location Well No. Level* High* Low* Average** (links to t S(::S
Monthly Overall national ,vter-level
database)
Barnstable ?30 26.3*** 20,5 26.6 -2.3 -2.6 413y5.60701.64301
Barnstable A4w 27.0 20.5 28.6 -2.4 -2.5 41415407016.5001:
Brewster BMW 21 13.3*** 6.9 13.3 -3.2 -3.1 414518070020.3.01
Chatham CGW 138 25.6 20.9 26.6 -1.5 -1.6 4141000700.1_l._10_l�
Mashpee MIW 29 9.8*** S.6 10.0 -0.9 -1.3 413.525070291.904
Sandwich � � 48.1 45.9 48.2 -0.3 -0.6 4144.1807024.1601
Sandwich SDW 54.6*** 45.8 55.1 -4.6 -4.5 414124070265901
Truro TS W 89 12.6 10.2 13.0 -0.3 -0.6 � 420206070045901.
Wellfleet WNW 12.1*** 7.3 12.8 -1.6 -1.7 4150.53.0.6958.5.401
lit.tp://w.\�iw.capecodcommission.org/wells.htm 9/18/2002
CD
rq
D'
c3 0 F L 2
Lr)
CD Postage $
ru
Certified Fee 7
O Postmark
O Return Receipt Fee Here
Q (Endorsement Required)
'r
0 Restricted Delivery Fee
(Endorsement Required)
a
p Total Postage&Fees s &,
o :Mr. &',Mrs.'Thbrnas R. Hennigan
i,129-Parsley Lane -
Osterville, MA 02655
Certified Mail Provides:
o A mailing receipt
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
is Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile.
o Certified Mail is no_t availAble for any class of international mail.
o NOiINSURANCE C6VERAGE IS PROVIDED with Certified Mail. For
valuables,please consid raln"sured or Registered Mail.
a For an additional fee,a Retu n Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)4the article and add applicable postage to cover the
fee.Endorse mailpiece%i t�i rn Receipt Requested".To receive a fee waiver for
a duplicate return rec 1pt,a USPS®postmark on your Certified Mail receipt is
required. ��
o For an additionalNt delivery may be restricted to the addressee or
addressee's authorized a ent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted-Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when.making an inquiry..
IPS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
SECTIONCOMPLETE THIS .
i Complete items 1,2,and 3.Also complete A. Signature �-
item 4 if Restricted Delivery is desired. ❑Agent
e Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by(Pont N C. Date of Delivery
N Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑wp,
Mr:,& Mrs. Thomas R. Hennigan
129.Parsley Lane
Qsterville, MA 02655 3. Service Type
❑Certified Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number + 7012 1010 0000 2850 918 7
(transfer from service labeO
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
1
I
I UNITED STATES POSTAL SERVICE First-Class Mail
I Postage&Fees Paid
I LISPS
Permit No.G-10
I
I • Sender: Please print your name, address, and ZIP+4 in this box •
n
Town of Barnstable
Public Health Division
I 200 Main Street
I Hyannis, MA 02601
X'
Town of Barnstable Barnstable
"s Regulatory Services Department `ac j
snRrisrnsr.e '
MAC. r Public Health Division
bs� 1Q' 2007
Fc ° 200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 .1010 0000 2850 9187
June 4, 2013 .
Mr. & Mrs. Thomas R. Hennigan
129 Parsley Lane
Osterville, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 129 Parsley Lane, Osterville, MA was last
inspected on 5/17/2013 by James D. Sears, a certified septic inspector for the
State of Massachusetts.
The inspection of the septic system showed.that the system "Fails" under the
guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• System is in hydraulic failure
You are ordered to repair or replace the septic system within sixty (60) days
from the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BO RD OF HEALTH
Thomas McKean, R.S. C
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\129 Parsley Ln Ost Jun 2013.doc
I 4
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10601
OY# II
T
"w
Logged In As: Parcel Detail � Tuesday,June 4 2013
Parcel Lookup
Parcel Info
Parcel ID 165-016 m Developeo� LOT 68
Location 1129 PARSLEY LANE I Pri Frontage 1128
Sec Road I Sec
Frontage
Village JOSTERVILLE Fire District C-O-MM
Town sewer exists at this address No I Road Index 12 �)
Interactive k
Map t �
_ .....SS.µ-.-., P....... ....
Owner Info
owner FHENNIGAN,THOMAS R&MARYLYN A —I
streets 129 PARSLEY LN I Street2
City�OSTERVILLE ( StateMA zip 02655_ Country C 1
7 Land Info
Acres 0.34 use Single Fam MDL-01 I Zoning�RC — ) Nghbd 0111 J
Topography Level I Road Paved
Utilities(Public Water,Gas,Septic , Location F _
Construction Info
Building 1 of 1
Year 1969 Roof Gable/Hip Ext Wood Shingle
Built Struct Wall
D: 3A
LivingAC
Area 2328 Cover Type Roof Asph/F GIs/Cmp Type
INoneBe
Style olonial weu Drywall Roomds I4 Bedrooms
C ,ill
e .
Int Bath
Model Residential HardwoodFull � �,. qu
Floor Rooms
Grade Average Plus Heat[.HHot�W�a�tter Total 9 Rooms.
I 9 I Type 1 ( Rooms I t = N
81Heat
111 u
stories 2 Stories Fuel Gas )Foation Poured Conc. k
Asa
Gross 5426
Area
Permit History-- -- --—. -.._._.— - .__
http://issgl2/intranet/propdata/ParceiDetail.aspx?ID=10601 6/4/2013
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10601
Issue Date Purpose Permit# Amount V Insp Date Comments
10/3/2003 New Roof 72069 $15,000 2/24/2004 12:00:00 AM
9/15/2003 Addition 71502 $15,000 2/24/2004 12:00:00 AM
4/23/2003 Remodel 68303 $6,000 2/24/2004 12:00:00 AM
- Visit History
Date Who Purpose
4/25/2008 12:00:00 AM Paul Talbot Cyclical Inspection
11/17/2004 12:00:00 AM Paul Talbot Meas/Est
2/24/2004 12:00:00 AM Martin Flynn Bldg Permit Completed
4/7/2003 12:00:00 AM John Greene Cycl Insp Comp
2/25/2003 12:00:00 AM Paul Talbot Meas/Est
9/28/1999 12:00:00 AM Donna Dacey Meas/Listed-Interior Access
Sales History
Line Sale Date Owner Book/Page Sale Price
1 11/22/2002 HENNIGAN,THOMAS R&MARYLYN A C167366 $500,000
2 3/15/1991 ELLIS, DONALD E& LOIS J C122850 $200,000
3 3/15/1991 SEIBERT, PAULINE S C122849 $1
4 9/15/1984 SEIBERT,WALTER&PAULINE S IC49114 $0
Assessment History
Save# _Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2013 $203,300 $59,900 $9,300 $346,700 $619,200
2 2012 $207,900 $58,000 $7,400 $346,700 $620,000
3 2011 $253,400 $4,000 $0 $346,700 $604,100
4 2010 $253,900 $4,000 $0 $346,700 $604,600
5 2009 $269,600 $2,600 $0 $425,300 $697,500
6 2008 $275,800 $2,600 $0 $443,100 $721,500
8 2007 $274,700 $2,600 $0 $443,100 $720,400
9 2006 $255,900 $2,600 $0 $406,600 $665,100
10 2005 $225,800 $2,600 $0 $304,000 $532,400
11 2004 $173,100 $2,500 $0 $304,000 $479,600
12 2003 $164,800 $2,500 $0 $150,900 $318,200
13 2002 $164,800 $2,500 $0 $150,900 $318,200
14 2001 $164,800 $3,000 $0 $150,900 $318,700
15 2000 $121,900 $4,300 $0 $67,000 $193,200
16 1999 $121,900 $4,300 $0 $67,000 $193,200
17 1998 $121,900 $4,300 $0 $67,000 $193,200
18 1997 $127,100 $0 $0 $53,600 $180,700
19 1996 $127,100 $0 $0 $53,600 $180,700
20 1995 $127,100 $0 $0 $53,600 $180,700
21 1994 $119,200 $0 $0 $78,400 $197,600
22 1993 $119,200 $0 $0 $78,400 $197,600
23 1992 $135,600 $0 $0 $87,100 $222,700
24 1991 $163,100 $0 $0 $87,100 $250,200
25 1990 $163,100 $0 $0 $87,100 $250,200
26 1989 $163,100 $0 $0 $87,100 $250,200
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=10601 6/4/2013
•: • 1 1 1 '.I '.1 ' . 1 1 • 1 1
• •�• • 111 ' 1 ' 1 ' • 11 •� 11
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�7DR�AI J
_ *w Commonwealth of Massachusetts
Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
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 filling out forms A. General Information
on the computer, OF I ugp�4i,
use only the tab J T�/► �``�� S' ��i
1. Inspector: I
key to move your
cursor-do not o
use the return James D.Sears z: JAMES .CP
key. Name of Inspector =00 SEARS :-+
CapewideEnterprises,LLc
ILA Company Name
153 Commercial Street �'��i`F 5 INS
11
Company Address mnunnt
Mashpee— MA 02649
City/Town State Zip Code
508-477-8877 S1623
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:
0 Passes ❑ Conditionally Passes' ® Fails
E' Needs Further Evaluation by the Local Approving Authority
.,5-18=13
actor's Signature Date
The system inspector shall submit a copy:of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall;submit the-
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report-only describes conditions at the-11me of.inspection and under the conditions of use .
at.that time:This inspection does not address-how�•the..system4lit'-peiforvit4w-tt-feature under
the same or different conditions of use.
�(•l�
g vl�
t5ins-`3/13 Title 5 txripaf lns Form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfrltration 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.
Q Y El N ❑. NO(Explain below)-
t5ins-3/13 Tice 5 Official inspection Form:Subsurface Sewage Disposal System•Page.2 of 17
i
Commonwealth of Massachusetts
Title 5 official Inspection, Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cons):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ 'N ❑ `ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurtaee Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
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 Tess 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 .
E ® '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 YZ day flow
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Cityrrown State Zip Code Date of Inspedion
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No ,
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
-system in accordance with 310 CMR 15.304. The system.owner should contact the appropriate
regional office of the Department.
t5ins 3/13- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.'a 129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the apanw.manholes,uncovered, opened, and the interior 111t
inspected for the condition of the tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is Osterville MA 02655 5-17-13
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
The system is Three cesspools.
Number of current residents: ;
2
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2911-165,000Gal
g ( y g (gp ))' 2012-112,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 129 Parsley Ln.
Property Address
Thomas Hennigan
Owner owners Name
information is required for every Osterville MA 02655 5-17-13
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: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owners Name
information is required for every Osterville MA 02655 5-17-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of information:
1960's-per Owner Records
Were sewage odors detected when arriving.at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction: .
❑cast iron ❑40 PVC Orange Burge
®other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is Orange Burge
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:
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owners Name
information is required for every Osterville MA 02655 5-17-13
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
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(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth-of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 129 Parsley Ln.
Property Address
Thomas Hennigan
Owner owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Cityfrown State Zip Code Date of Inspedion
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hannigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 129 Parsley Ln.
Property Address
Thomas Hennigan '
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 2
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two blocks c.pools. Pools are 3'below grade w/cover's at 5"and 10",1 8"cement cover's.
Both pool's are full, not leaching.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration 1
4"
Depth—top of liquid to inlet invert
Depth of solids layer 411
Depth of scum layer 21'
Dimensions of cesspool
6'
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 13 of 17
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner owner's Name
information is required for every Cisterville MA 02655 5-17-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Main c pool, inlet line orange burge. Pool at 2' below grade w/cover at 5" 18"cement cover. Water
level over outlet line's
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
i
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5ins-3113 Title 6 official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
i
' Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5-17-13
page. Cityrrown 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
6
01
13-1 -
3 y3;s �r
s
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
129 Parsley Ln.
Property Address -
Thomas Hennigan
Owner owner's Name
information is Osterville MA 02655 5-17-13
required for every
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 13'+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)
y. _
❑ 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:
Past report and abutting property in area.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Fonn: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
129 Parsley Ln.
Property Address
Thomas Hennigan
Owner Owner's Name
information is required for every Osterville MA 02655 5.17-13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ASSESSORS MAP : �I(o� NOTES:
----- TEST HOLE L E LOGS G S
PARCEL:
! �-� SOIL EVALUATOR : '/'1�� � 1 The installation shall comply with Title V and "Town of Board of
FLOOD ZONE: �t� ► AF�'L� C -� ) P Y ` ,
— — - WITNESS : 1 b Health Regulations.
REFERENCE: o7 DATE: I 2) The installer shall verify the location of utilities, sewer inverts and septic
PERCOLATION OAT : l I + components prior to installation and setting base elevations.
3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first
two feet out of the d-box to the leaching shall be level.
TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other
(� LOP,
►+ ( LOW purpose other than the proposed system installation.
""v ( a 2 1 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
Lbj p� 7) The property bounded
is bded by property corners and property lines.
a considerations to approve of total
L O C A T I O N MAP 8) The property owner shall review design n v w es g pp
t� design flow and number of bedrooms to be considered for design. Receipt
' ''�✓a of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
C 4 9) The existing leaching or cesspools shall be pumped and filled with material
per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
Title V specs.
�+ 10)System components to be 10 feet from water line. Sewer lines crossing the
c) water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
applicable. The proposed SAS is being installed below the water service
- -- ! line. The line is to be sleeved as aforementioned and maintained in place.
SEPTIC SYSTEM DES I GN
l --=---_ 11) If a garbage grinder exists it is to be removed and is the responsibility of the
c5 g,y a /Zz, \ �``' ---___ owner to ensure such.
— FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
exists.
BEDROOMS AT 11D GAL/DAY/BEDROOM - GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
lines exiting the dwelling prior to the installation.
-� SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
Title V requirements.
^ IQ 4LILGAUDAY x 2 DAYS - GAL
USE I GALLON SEPTIC TANK
ABSORPTION S S M-
+�x 0
r) SIDE AREA:
QQ
N N t� BOTTOM AREA: "; �Z�
N gNlTAR%P
SEPTIC SYSTEM SECTION
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(10
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97
SAL
SEPTIC TANK i ` :2
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33•
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—�.;�u.� off' %►� _!��_� ,
S I TE AND SEWAGE PLAN
LOCA*r I ON : l Z � f-
PREPARED FOR : Z I1M
MA
SCALE :
W I)AV I D B . MASGN R5 DATE : gob
z DBC ENV I RONMENYAL DESIGNS
Z CAST SANDWICH . MA
ENT DATE HEALTH AG
W ( 508 ) 833- 2177
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