HomeMy WebLinkAbout0207 PINELEIGH PATH - Health 207 Pinefeigh Path
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� `' , Commonwealth of Massachusetts .,
fia s Title 5 Official Inspection Fora ' _ -
1�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /
207 Pineleigh Path k; i 4 t
Property Address
Charles and Geraldine Crowley ,: {
Owner Owner's Name
information is
required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspectionrforms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information
Shawn Mcelroy
Name of Inspector •'' ° +{ ' I'
Wiper Cape Septic Services
Company Name '
P.O. Box 73
Company Address
East Falmouth MA'� 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:) 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 atgtheproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based_on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by-the Local Approving Authority
4. ❑ Fails
- 5-13-20
I ector'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 Comhibm' ealth'of Massachusetts
Title 5 Official Inspection F rm
O
wa
p
`ate
Not for Voluntary Assessments A Subsurface Sewage Disposal System Form=
207 Pineleig h Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is Osterville MA 02655 5-13-20
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:.
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
E
2) System Conditionally Passes:
❑ One or more system components as described in the "ConditionalPass" 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 over20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is,replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
> cc
207 Pineleigh Path
Property Address F
Charles and Geraldine Crowley
Owner Owner's Name
information is
required for every Osterville MA 02655 5-13-20. .
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes,(cont.):
❑ Pump Chamber pumps/alarms not operational..System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval'of Board of Health):
❑ broken'pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed - ` ' ❑ Y ❑N •❑ 'ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
r. � . . .
4,
❑ 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 El El ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the.Board of Health in order to determine if
the system is failing to protect public health,"safety or the environment."
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:`
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for-Voluntary'Assessments
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of'a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes - No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts i
Title 5 Official Inspection Form
C�i Subsurface Sewage_ Disposal System Form -Not for Voluntary Assessments
207 Pineleigh Path
Property Address a '
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) i
4) System Failure Criteria Applicable to All Systems: (cont.)
A i �.
Yes ,No
0 ® Static liquid level in the distribution box above odtlet,invert due to an overloaded
or clogged SAS or cesspool `. '`
❑ ® Liquid depth in cesspool is less than,6" below invert or available volume is less
than day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
❑ ®• Any portion of the SAS, cesspool.or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
❑ ® tributary to a'surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well. '
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
,
❑ ® Any portion of-a cesspool or'privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.],.
❑ ® The system is a;cesspool serving a facility' with a design flow of 2000 gpd-
10,000 gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
� necessary to correct.the failure:
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.- ' L.
For large systems, you must indicate,either"yes" or"no",to each of the,following, in addition to the
questions in•Section CA. ,
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
(A i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'�� g p Y rY
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary(cont.) -
If you have answered "yes"to any-question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
,under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for aH inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility.or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components;excluding the SAS, located on site?
®' ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at.the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
C Commonwealth of Massachusetts
fia s Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
�.,-•�-. , 207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is Osterville MA 02655 5-13-20
required for every '
page. City/Town _ State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: r. • ,, , r , ,, :k >
Number of bedrooms (design): 5 Number of bedrooms (actual): 7
DESIGN flowbased,on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):, 550
Description:
Number of current residents: ,± r + 0
Does residence have a garbage grinder? 7 • .� ❑ Yes ® No
Does residence have a water treatment unit? . - _ ,:; 1 ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.) '
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
N •F {i
Sump pump? ,- ;; ❑ Yes ® No
Y.
Last date of occupancy: 2020Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-
••_ . :
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions: `
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
f
c Commonwealth of Massachusetts
.� ,r4 Title 5 Official Inspection Form, ..r
PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
� tic
14>'1 207 Pineleigh Path
Property Address
Charles and Geraldine Crowley t ,
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20.
P'
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,, -►:
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool ,•- ,�
❑ Overflow cesspool.,
❑ Privy
❑ Shared system (yes or no) (if.yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract-
❑ Tight tank.Attach a copy of the DEP approval. •�
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1993
Were sewage odors detected when arriving at the site? , ❑' Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 30"
feet
Material of construction:
❑ cast iron Z 40 PVC 1' ❑ other(explain):'
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r� r
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 24"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:
2000 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle "
26"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle '
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of failure.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,r. Title 5 Official Inspection Form,
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
r;+n'
207 Pinelei h Path
Property Address t
Charles and Geraldine Crowley ,
Owner Owner's Name
information is required for every Cisterville MA 02655 5-13-20 ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan): ? ., r - ,N r ,
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: w - ' 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:):
r-
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
�-r
Title 5 Official Inspection, Form
i,-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is Osterville MA 02655 5-13-20
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):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pits.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts - .
Title 5 Official Inspection Form
hi Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
> „c
207 Pineleigh Path • �, ' ;,., ,>
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is Osterville MA 02655 5-13-20
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .r
10. Pump Chamber(locate on site plan):
Pumps in working order: ' ❑ Yes ❑ No*
' Alarms in working order: : ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.it
11. Soil Absorption System (SAS) (locate on,site plan, excavation not required): �
If SAS not located, explain why:
Type:
2-1000 gal
® leaching pits " ' r number: -
❑ leaching chambers number:
❑ Teaching galleries - number:
❑ leaching trenches number, length:
❑ leaching fields • number, dimensions:
❑ overflow cesspool ' number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
$1 ,w. Title 5 official Inspection Form
i-'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r >r` 207 Pineleigh Path
�l
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osteryille MA 02655 5-13-20
'
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.):
Leach pits in good working order and empty at inspection with no visible stain lines in pit marked "5".
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes , ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts _
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �
207 Pineleigh Path
Property Address t, _
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville ^` MA 02655 5-13-20
'
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: ,}
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r -
r.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r ,
� ,. 207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
1
1
4 q
�."
3
7W03 '
4 pr YJ
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
f
Commonwealth of Massachusetts. ., • , , . . • .
3 Title 5 Official - Inspection Form r
hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley 7 ,.
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,.I• ;_ ". " I ,s y ' .r
15. Site Exam: t t, ti
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells r
Estimated depth to high ground water: t ,; 204
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,•date of.design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
$1 4 , Title 5 Official Inspection Forme
i t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
207 Pineleigh Path
Property Address
Charles and Geraldine Crowley
Owner Owner's Name
information is required for every Osterville MA 02655 5-13-20
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
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6'-0" 91-5"
15'-4"
o
15'=6"
Owner 3
Gera l di?e
'24 Lanark. Road
Wellesley, MA 02181
Map 071 Parcel .001/010
Property Address
Pinel eigh Pa
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�P 4
G , TOWN OF BARNSTABLE
LOCATION •4-_ 11np(ei SEWAGE
VILLAGE QVS-wA ASSESSOR'S MAP & LOT
INSTALLER'S NAME'&-PHONE NO. 4J
SEPTIC TANK CAPACITY
v
LEACHING FACILITY:(type) (size) X /y�.�
NO. OF BEDROOMS J PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER i Lyi A. + �1;s'i Pr
DATE PERMIT ISSUED:
J.
DATE COMPLIANCE ISSUED: 93
VARIANCE GRANTED: Yes No
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No. -• ........... ...... ., ,
THE COMMONWEALTH OF MASSACHUSETTS •")C %_ Cy)j CJ`Q
BOARD OF HEALTH _-- ---'
TOWN OF BARNSTABLE
Appliration for Di►ywia! Wurku Towitrurtion Errant
Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
System at: ,
.............................................9,o7 Tl^ lGl PAr s`i -R AhP -�/ Ma:z /o
J
......•....._..-__._... ....
................
� /o .// dj��ss/ /� or Lot No.
wy..Y
Ouncr Address
Installer Address y3 s62
Type of Building Size Lot...___..._.l._...._.2....Sq. feet
Dwelling— No. of Bedrooms------------ ---------------------------_-Expansion Attic ( ) Garbage Grinder (I
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
p, Other fixtures ---_-----_------------ ------
OPRI
w Design Flow.........//o-------------------------_-gallons per-pefset; per day. Total daily, flow---------770..........................gallons.,
04 Septic Tank—Liquid capacitvlgV..gallons Length---1.�I_._ Width_& _ ._...... Diameter---------------- Depth.....]. ""
W '
Disposal Trench—No. .................... Widt 1...._ ..j.._._____.. rotal Length--.__- _.......sq. ft.
x p j p---------
Total leaching area............
Seepage Pit I�'o..__..2...-_._... Diameter. _,W 3 S Deptll below inlet.. .......:..... Total leaching area...6.7�.....sq. ft.
z Other Distribution box ( ) Dosing tank ( ) j �3 D //
Percolation Test Results
Performed bY--------->°__.Ss/<<I_Y�!J_....1-�..T-------------------- Date......����l. 9��___. ...�
a
,.� Test Pit No. 1................minutes per inch Depth of Test Pit..........-......... Depth to ground water-.N..-......t�..
Gi. Test Pit No. 2................minutes per inch Depth of Test Pit.-.--_------__-- Depth to ground water........................
04 ........r......------------•--- • ---•------:----------.... r........ -- ---•---•--.-
Description of Soil �' CoN�?+� --Su-�?Sa�.�. /S ?0- N1iE�l V1( 1. SAr��-.....................................
x
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code— e undersigned further agrees not to .place the
system in operation until a Certificate of Compliance h en i ed by the board of health.
Signed ........ ............ .. ....................................... ...
Application Approved By . .............
Q
...... ... .. ... ... .. - ---..... . ......................... A91
..... :_
Application Disapproved for the following reason : ............. .............. . ...................................... ... . . ...............................
................... .. .... .. ........--....... ........---................ -- ... ...............:....
re
PermitNo. ............. ........ ......... ....................... Issued ............. .
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�: .-.. � M fit' \./ �� Y—\✓ � �. ..
9: . Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS 4a�/ �/ OHO
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripmial Wi orko Towitrurtinn ranfit
Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
System at:
-..... to�.. '�^� l�l...� ------... Tf ---- a-�R- ------------ � - ALL �'� __... -....
Loc ,lion or Lot No.
owner Address
�. <1.. c_cXim---------------------------------------- ....... --------- ......ir t I_h ................................
Installer
� Address y3 s62
Type of Building � Size Lot.... ___________....Sq. feet
Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other—Type of Building N of ersons---------------------------- Showers
a YP g ------------------------.... o. P ( ) — Cafeteria ( )
dOther fixtures -------------------------------- ------------------------ .............................................................
w Design Flow........./10............................gallons per .scam per day. Total daily flow.......--�10..........................gallons.
WSeptic Tank—LiquiTd capacity.7�V_-gallons Length..-f.//'.. Width.hr-.57 ... Diameter................ Depth..- ...Cuff
x Disposal Trench—No. .................... Width...............--. Total Length---------`_......._ Total leaching area....................sq. ft.
3 Seepage Pit No------2.......... Diameter.6..1AJ/f Depth below inlet._.16............. Total leaching area....�.7&_....sq. ft.
z Other Distribution box ( ) Dosing tank ( ) ��7330
aPercolation Test Results Performed by..-_-._.-�....S.�l / � ..............�..................... Date......
4 Test Pit No. I .....minutes per inch Depth of Test Pit-------1A........ Depth to ground water,VomF.-�'��^�-U
(1 Test Pit No. 2................minutes per inch Depth of Test Pit.................--. Depth to ground water........................
� .........;-------o --- ---•-•.. ••........._••••-••....... .:. ..........................................
Description of Soil Q 1�. ....-•-- A>,�...<.kti�, Z. /.es.-- !4--- �'E-��-1! M'i_..1
x
w
UNature of Repairs or Alterations—Answer when applicable..............................................................................................! -.
••••-•-•••----------•--•---•-----......••-•••---...•------•----•--------------••--•••-••-••-•--•.....---•------.......----...-------•-----•-••------•------•••--- ......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code— e undersigned further agrees not to place the
system in operation until a Certificate of Compliance h een i ed by the board of health.
Signed ................. ............_- : �....' /'.:......
l
Application Approved By �... -/-!------ .. . ........... ...� le ....1 2
Application Disapproved for the following reasons /... -' . ............................................................................ ... ...................
.................................................. ---_ .....�Z ../n.........................................................'. ..... ..... ....... _/�----- 1........r .
Permit No. ........... .� 2.. Issued .............fDa �.... I .. .......
Permit No- -----?
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#ifi ate of Contylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( � or Repaired ( )
by ....... . ... _.----------- ----......
. ..._........'..........._. ..........._--------------------------------------------
ti " Insrdlcr
22',
atQ 7- ......................LZ' . _..�A-c�F- ..(�c,S /Q...--�} !,v -----------' ......................................................... ........................
has been installed in accordance with the provisions of TILE �of The t vironmental Code as described in
the application for Disposal Works Construction Permit No. .GS�J� St e ..... dated .._............_._. ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................__�._ -.r...��" ...._.-_.... ............._... Inspector ..__.. ........ 1
v _....... r".i... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I �-'' TOWN OF BARNSTABLE FEE.--•-
No.....�....------••-------
�io�r.00�tl or�o �na�o#r�r#ion ��ermit
Permission is hereby granted------------ rX ..:...-----------------------------------------------------------------•------...........--
to Construct ((/�/or Repair ( ) an Inc ividual Se e Disposal System
at No........................2Q7---••...... ✓e_�c!T �17 p,� ? ---------1--......
street /
as shown on the application for Disposal Works Construction Permit No�_.. .�. I�ated.......��`
..................................... ---------------------------------- •------•-------•-
+ Board of Health
DATE-----------�..,a-._'..... .............................
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
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Oyster Harbors Revisions:
j DAIE D
i Co tuft
Assessors Map 71 Parcel 1-9 gay /
N/F j
Mitchell, Mathew J. o� �, West
Birmingham, R.M. BayCL
.
Murphy, H.L. tacos
,P o
.21.0 •21.6 .22.3
/D .21.4 21.6
CB H Found CB/DH Found
.21.2 L __ ea
l .20 5 S 88.01 28 E .717 1 Test Ri,,er
291.79'
T References:
.22.1 I 1 � Ssapuit River
I �--- Land Court Plan 15354-127
N
Scale:l"=2083' Land Court Certificate 119537
21.3 M LOCUS MAP F.E.M.A. Benchmark RM 42
I
.20.3 .21.4 I Assessors Map 71 Parcel 1-10
.21:2 l
® i ,Zone R 1
.20.2 0.6 = Min. Lot Area 43,560 SF
.19.6 ® .21.1 I Min. Lot Frontage 20'
� J
Utilityl Pole k1a, Yard 2J acks:
.20.3
O '�`' 110 1.1 i Fron t .30'
-20. Slde 15
c0 `N u� .20.8 ® v •�. Rear 15
001. oe 1,000 Gal. Pi �.0
r s `®Q �'��cy�` �4�0& a W/3' Stone Q-
Q 4eU- I
.20.6 g b / '�' lO n Project .
9.7 C� OQ0°�001 ��'
50' Min. Setback .""_.'' �. � .2p � ♦ RESERVE
®c .20.4 c iC` �" t / J •19.9 lw
0% Proposed D-Box v+' lg 1
°i 43,562 S.F. Q tO b 3- 20.7 #207
1.0 Acre ec x+ ao 0
19.5
.0
Pineleigh
Assessors Map 71 .20.7 20.6 I
Parcel 4-1 AOr . .2 I I Path l
/F .20.3 2.5• / ® / /\, � '20.6 sty
Oyster Harbors Club Inc.
19.1 Min. RESERVE
.20.5 S 2/ / � ��n I
I n
-1,000 Gal. Pit OQogea .20.3 I ( Osterville )
.20.7 -01 0 W/3 Stone Q� Hyd {
:11W .20.3 W W 0.� atergate
IBarnstable ,
285.39' I
N 88.3657" W 1.3
19.2 CBA�i Found •20.4 2o.s 20.6 CB/DH Found Utility �016
Mao
. I
•21.1
, NCHMARK bi �
Concrete Bound EI.=20.10' N.G.V.D. Assessors Map/70 Parcel 24 PROPERTY LINES SHOWN HEREON WERE COMPILED FROM
N/F LAND COURT PLAN 15354-127 AND DO NOT REPRESENT
Birmingham, John P. Jr. Trs. AN ACTUAL SURVEY ON THE GROUND.
C/0 Mintz, Levin, Cohn, Etc.
ELEVATIONS SHOWN HEREON ARE BASED ON N.G.V.D. Silvia & Silvia
. Associates, Inc.
THE LOT SHOWN HEREON LIES WITHIN ZONE C AS DEPICTED ;•; BUILDERS * Rl;Monl;l.�ls * AZsIiRs
ON COMMUNITY PANEL NUMBER 25001 0018 C OF THE
FEDERAL EMERGENCY MANAGMENT AGENCY FLOOD INSUR- 619 Main Street
ANCE RATE MAP. Centerville, MA 02632
(508) 775-1442
911 Main Street
Osterville, MA
/'� 02655
To Of Founc�atlon E/,�23.0'
p 4" PVC 0 1/4" Per Foot (Typical)
a
Covers To Within 1' Of Fin. Grade A. M. Wilson Associates Inc.
Finished Grade
See Locus Ma Above For Location Of Test Pit See 2" Peastone S08 426 145� FAX 4?t3 1658
Test Pit On Subject Locus p
Locus Map Above For Location Of Test Pit First 2 Feet To Be Laid Level
18.0 ep c
Tank BOXDrawing Title
17
•
• 2,000 Gal. 3' Of 3/4" - 1 1/2-
Test PI't D®fa Test P/t ®®fg TeSf PIf D fQ 17.7 .1 3 Hole 16.9 co Pit Washed Stone
17.5 16.1 Indicates - Indicates Indicates 10.1 Subsurface
Groundwater _ Groundwater = Groundwater
_ �•�----- 3' 6' 3' Sewage
t 11' � 20, � I Disposal
Ground El.=20.1 - Ground El.= 10.0 � e� Ground El.= 20.6 Foundation - Tank - - D l s o s a l
P 7330 Loam & � 73L4 Topsoil P�7829 Design Flo .* ofe�• Design
Loam & 2 19.6 3 110 GPD/Bedroom x 7 Bedrooms = 770 GPD
Subsoil 18.6 Pit NO. 1 Subsoil 8.0' Pit No. Subsoil 18.6 Pit NO. C.Joll 1. Unless otherwise noted, all construction
P.Sullivan Y
Test By. Test By. Test By. methods and materials shall conform to
Test Date: 6/18/89 Medium Test Date. 6/15/89 11/7/91
Test Date: Title V of the state environmental code
J.Dunning (BOH) Sand Septic TOnk Requirements: Vith Garbage Grinder
Witness: o.Miaranai BOH and an applicable local regulations.
I4Itness. Medium Iyltness: ( ) 770 GPD x 2.0 = 1,540 Gallons y pp g
Medium 2. Precast concrete septic tank, d--box, �
Sand Perc Rate. <2 Min. Inch Adjust. Hi h 4.3 Perc Rate: <2 Min./Inch Coarse Perc Rate: Use 2,000 Gal. Tank
Ground Water Sand and leaching facility to withstand H-10
loading unless tender pavement, drives, P.JOLLY
Observed Water 2.4 V or travelled ways where H-20 loading CPAL
Leaching Facility Requirements. With Garbage Grinder shall apply.
770 GPD x 1.5 = 1.155 GPD J. All pipes In the system shall be schedule
Bottom 9.6 Bottom 0.0 Bottom 7.60 Based On Perc <2 Min./Inch 40 or equal.
No Water No Water Side Area Infiltration=2.5 Gal./S.F. 4. No field modifications to the sewage
Bottom Area Infiltration=1.0 Gal./S.F. dl.,posa/ system shall be made without �� �,
prior written approval of the engineer II
Leaching Faclllty Provided 2 - 1,000 Gal. Pits W/3' Stone and the local board of health. 10 193
Side:2TfRH = 256' 6' =(226 S.F.x 2.5 GPD/S.F.)2 Pits=1,130 GPD 5. Grout to be used at all points where
Bottom: Ti R' IT(6') 113 S.F. x 1.0 GPD/S.F. x 2 Pits - 226 GP pipes enter or leave concrete structures Scale: 1"= 20'
Total = 1,356 GPE In order to proNde a watertight seal.
® 20 40 50
Date: October 7, 1993 Dwg No:
Design: C.P.J.
Field: J.V.B./C.P.J.
Drawn: J.V.B.
ob No: 2.0663.0 Sheet 1 of 1