HomeMy WebLinkAbout0077 POND STREET - Health 77 Pond Street
Osterville
A= 118-028
®gip 08 2016 15:31 Jim The Inspector Man 5085349919 page 1 x
Commonwealth of Massachusetts
Title 5 Official Inspection FormrM
x o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Pond Street V
Property Address m
Eilzab_e_th O'Neil a
Owner Owner's Name /
information is Osteryille 1/ MA ' 02655 9-7-16
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered to any
way. Please see completeness checklist at the'end of the.form.
Important:When filling out forms A. General Information ' <S/ //8L3
`���1pulNrurp���
on the computer, "I'A OFA4,gs4i�4
use only the tab kp.•"' .�'q 4,
1. Inspector. ; . � �• •-' �-.�
key to move your %} S
cursor-do not J 3 •JAMES N
use the return James D.SearS :m z
ke Name of Inspector i s v c ci
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Ca wide Enterprises, LLC s �,o p;'
" Company Name ! •- •7 • ' ��`
153 Commercial Street yy s INSP�G�r�`�
Company Address t1 t1
I"
r�8071 Mashpee -i_ MA - .. 02649 City/Town Stale Zip Code
508-477-8877 91623
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:
M i ,
® Passes ❑ Conditionally Passes ❑ Falls
1 .
Needs Further Evaluation by the Local Approving Authority
l
_ i 9-7-16
pector's Signature i 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
-
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the some or different conditions of use.
.15ins.doc•riv.6116 - - -Title 5Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 1 of 17 -
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Sep 08 2016 15:31 Jim The Inspector Man 5085349919 n ; page 2
Commonwealth of Massachusetts!,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is required for every Osterville MA 02655 9-7-16
page. City/Town i State Zip Code Date of Inspection
B. Certification (cont.)
}
Inspection Summary: Check A,B,C,D orj E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 16.304 exist.Any failure criteria not evaluated are "
indicated below.
i
Comments:
The system is a block c. pool and trench.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional.Pass'section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass. .
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally
unsound;exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced'(with a complying septic tank as approved by the Board of
Health.
i I
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):w
i
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Sep 08 2016 15:31 Jim The Inspector Man 5C85349919 page 3
i
°•� Commonwealth of Massachusetts I
W Title 5 Official Inspection Four,
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -
j .
•%� 77 Pond Street j
Property Address
Eilzabeth O'Neil I
Owner Owners Name
information is required for every Osterville ' MA 02655 9-7-16
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. ! -
B} System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level.in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box..System will
pass inspection if(with'approval of Bbard 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):
i .
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is
❑ 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 j ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
• i
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to.protect public!health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is notfunctioning 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'60c'•tev.6/16 Title b Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
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Sep 08 201E 15:31 Jim The Inspector Man 5085349919 page 4
o Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
r 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is
required for every Osteryille MA 02655 9-7-16
page. City/Town I State Zip Code Date of Inspection
B. Certification (cont.)
j
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:
I
❑ 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.
El The system has.a septic tank and SAS and the SAS is within 50 feet of a.private water
i 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". z
Method used to determine distance:
'* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates.absent and the presence of ammonia nitrogen and.nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form:
3. Other:
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l
I
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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 EORM is less than 6" below invert or available volume is less
than '/z day flow J-,6� CAIv�
i
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Sep 08 2016 15:31 Jim The Inspector Man 5085349919 page 6
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments -
� 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is required for every Osterville MA 02655 9-7=16
page. Cityfrown, State Zip Code Date of Inspection .
B. Certification (cont.) -
Yes No
® Required pumping 'more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped.
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply:
❑ ® Any portion of a cesspool or privy is within a Zone.1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes If the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]El Z .
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
E ® 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 gp;d. "
i
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 {
i
❑ ❑ the system.is within;400 feet of a surface drinking water supply,
j
❑ ❑ the system is withi 1200 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.
'i
t5ins.doc rev:5115 Title 5 Official Inspection Form.Subsurface Sewage Disposal System"Page 5 of 17
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Sep 08 2016 . 15:32 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments-
_ I .
77 Pond-Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
iq ti is
required for every Osterville ' MA 02655 9-7-16
page. Cityfrown 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 b the owner, occupant, or Board of Health i
Y p I
❑ ® . Were any of the system components pumped out in the previous two weeks? i
® ❑ Has the system received normal-flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z ❑ 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? j
i
® ❑ Were all system components, excluding the SAS, located on-site?
® 0 Were the manholes uncovered, opened, and the interior
inspected for the condition of the tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth.of scum?
t ❑ ® Was the facility owner(and occupants if different from owner) provided.with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has.
been determined based on
I
❑ 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): 2 -
DESIGN flow based on 310 CMR 15.203 (for example:.;110 gpd x#of bedrooms): 220
15iru.doc•rev 6n 6 : Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Sep 08 2016 15:32 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4� 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is
required for every Osterville MA 02655 =9-7-16
page. City/Town State Zip Code ':Date of Inspection
D. System Information
Description:
The system is a bkock c. pool and trench.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ®. No
Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? El Yes ® No
Water meter readings, if available last 2 ears usage d 2015-65,000Gals
g ( y (9P ))' 2016-22,000Gal's
Detail
t
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? El Yes ❑ No
Industrial waste holding tank present? i ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
16ins.doc-rev.6116 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 7 of 17
Sep 08 2016 15:32 Jim The Inspector Man 5085349919 page 9
r i
Commonwealth of Massachusetlis
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
y 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is Osterville
required for every MA 02655 9-7-16 '
page. City/Town t State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
Y
General Information
I
pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 800 Gal.
gallons
How was quantity pumped determined? Gage on pump truck
Reason for pumping: Part of inspection
T _
.Type of System:
i
® 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)
i
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained fromsystem,owner)and a copy of'latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval. "
❑ Other(describe):
15ins.doc•rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Sep 08 2016 15:32 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-
�» 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information Is OStervllle
required for every MA 02655
page. City/Town State Zip Code Date o6lnspection
D. System Information (cont.)`
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site?
Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
3' ,
feet
Material of construction:
❑ cast iron ®40 PVC []other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition"of joints, venting, evidence of leakage, etc.): .
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan).-
.Depth below grade
feet
Material of construction:
❑ concrete metal i [],fiberglass ❑ pot ethi lene
i
y y ❑ other(explain)
E
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i
If tank is metal, list age:
years
%. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El. Yes ❑ No
Dimensions:
'
Sludge depth: -
15ins.doc-rev,6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
Sep 08 2016 15:32 Jim The Inspector Man 5085349919 page 11
Commonwealth of Massachusetts
Title 5 official Inspection F®rrn
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond Street
Property Address
Elizabeth O'Neil _.
Owner Owner's Name
information is OStervllle
required for every MA 02655 9-7-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cone)
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 (an pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
4
Grease Trap (locate.on site plan):
Depth below grade: feet
Material of construction:
El concrete ❑ metal ❑ fiberglass, ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
a 2
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
h
t5ins.doc-rev.6116 Tr la 6 Official Inspeclion Form:Subsurface Sewage Disposal Systen•Page 10 of 17
Sep 08 2016 15:32 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
tion is required for every Osterville
MA 02655 9-7-16
page, Citygown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, .
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑ metal ❑ fiberglass El polyethylene Elpol eth y y other(explain):
Dimensions:
Capacity:
gallons
Design Flow; gallons per day
' Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes 0 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
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.Sep 08 201E 15:32 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
Title 5 official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond Street
Properly Address
Eilzabeth O'Neil
Owner Owner's Name -
information is
required for every Osterville MA QZ655
page. city/Town State Zip Code Date� 161nspection
D.. System Information (cont.)
Distribution Sox(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No Box
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
_ evidence of leakage into or"out of box, etc.):
I
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.doc• ev.6116 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 12 of 17
Sep 08 2016 15:33 Jim The Inspector Man 5085349919 page 14
i
Commonwealth of Massachusetts
Title v Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 77 Pond.Street
Property Address
i Eilzabeth O'Neil
Owner Owner's Name ti
information is Osteryille MA 02655 9-7-16
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.) }
Type.
❑ leaching pits number:
❑ leaching chambers number:
•❑ leaching galleries number:'
z leaching trenches number, length:
1 -26'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system ,
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.): -
Leaching is a trench. Camera out line clean and no sign of holding water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert 6
61,
Depth of solids layer
i
i' 211
Depth of scum layer
F
71
Dimensions of cesspool
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
15ins.doc .ev.6116 Title 5 Official In"oon Form:Subsurface sewage Disposal Syslem-Page 13 of U
Sep 08 2016 15,33 Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M . b 77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is
required for every Osterville MA 02655 9-7.16
page. Cityfrown State Zip Code Date of Inspection
D. System Information (Cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Main pool at working level. Main pool 7' block old.c.pool w/cover.at 4" below grade. One line in.
Outlet w/tee
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.):
15ins.doc•rev.6/16 Title 5 Official inspect on Form Subsurface Sewage Disposal System•Page 14 of 17
Sep 08 2016 15:33 Jim The Inspector Man\5085349919 page 16
Commonwealth of Massachusetts
ti Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
77 Pond Street.
Property Address
Eilzabeth O'Neil
Owner Owners Nameinform v
require for
is Osterville MA 02655 9-7-16
required for every
page. City/Town State Zip Code Date of Inspection
D.-System Information (cont.)
Sketch Of Sewage Disposal System:.Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate.all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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151ns.doc••ev 6116 e' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Sep 08 2016. 15:33 Jim The Inspector Man 5085349919 page 17
Commonwealth of Massachusetts
Title 5 Official Inspecti®n Pori
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
77 Pond Street
Property Address
Eilzabeth O'Neil ..�.
Owner Owners Name
information is
required for every Os terville MA 02655 ' 9-7-16 l
page. City[Town State Zip Code Date of Inspection j
}
D. System Information (cont.)
• I
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
12'+ .
Estimated depth t tigh ground water: feet .
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
❑ Observed site (abutting property/observation hole within 150 feet of SAS) i
® Checked with local Board of Health -explain: I
Perc Test 6-24-14 12'+ no G.W.
❑ Checked with local excavators, installers -(attach documentation)
El I
Accessed USGS database-explain:
• I
I
You must describe how you established the high ground water elevation:
- i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
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Sep 08 2016 15:33 Jim The Inspector Man 5085349919 page 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond Street
Property Address
Eilzabeth O'Neil
Owner Owner's Name
information is required for every Osterville MA 02655 9-7-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked I
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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+ I
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t5ins dx•rev 6/16 Title 5 Official Inspection Form:Subsurface Sewege Disposal System•Page 17 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,- Not for Voluntary Assessments
77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out n�
forms on the
computer, use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
Cityrrown State Zip Code
(508)477-8877 S 14454
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 CM 15.000). The system:'
® Passes ❑ Conditionally Passes ❑ Fails 1 M'a
❑ Needs Further Evaluation by the Local Approving Authority
F.-3
3/16/2011 '
Insp ctor's ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(B and
of Health or DEP)within 30 days of completing this inspection. If the system is a shared gy`stem or
has a design flow of 110,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
/ / I
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dispo all System•Page 1 of 17
i r
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osteryille Ma. 02655 3/16/2011
every page. CitylTown 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:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to,a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is Osterville Ma. 02655 3/16/2011
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M 77 Pond.St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osteryllle Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
ElRequired 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— IW PA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
n® [I Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information —
Residential Flow Con tions:
Number of bedrooms (de ' n): 3 Nu er of bedroom actual): 2
DESIGN flow based on 310 CMR 3 (for ex e: 110 gpd x#of bedrooms):
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
wM 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is Osterville Ma. 02655 3/16/2011
required for �
every page. City/Town 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:
r
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ® other(explain):
orangeburg
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
,M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osteryille Ma. 02655 3/16/2011
every 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
44
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
wM 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information Osterville Ma. 02655 3/16/2011
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 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
M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1-26'x2'x2'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Trench was dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1-Main 1-Overflow
Depth—top of liquid to inlet invert
3'
Depth of solids layer
4"
Depth of scum layer
V.
Dimensions of cesspool 6'x8'
Materials of construction Concrete Block
Indication of groundwater inflow ❑ Yes ® No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
• II
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information.is required for Osterville Ma. 02655 3/16/2011
City/Town/Town State Zip Code Date of Inspection
every page. Y P p
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Sandy soil.No signs of hydraulic failure.Stain line in main CP was up to outlet invert.Overflow CP was
dry.Stain line observed 3' below invert.
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/1C Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information is required for Osterville Ma. 02655 3/16/2011
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: Bottom Of CP 10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (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:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
4 Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
77 Pond St.
Property Address
Milne Trust
Owner Owner's Name
information i5
required for Osteryllle Ma. 02655 3/16/2011
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
p i
Commonwealth of Massachusetts
Title 5 Official Inspection Form ;
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond st
Property Address
Colleen Gallagher '
Owner Owner's Name/
information is Osterville y Ma. 026556 6-16-20
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites path
Company
r� Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
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 y�``p '' • ��
• ado•:MICHAEL`yN
3. ❑ Needs Further Evaluation by the Local Approving Authority __`o; SEARS
No.SI14430
4. ❑ Fails % �'• o
•FRTIO
pSIp, G`
6-16-20
Ins ector's nature' Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.1 of 18
Commonwealth of Massachusetts
,�-p Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
11 I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V!% 77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
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):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
`I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
U—
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ 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
�w Title 5 Official Inspection Form
tii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............ 77 Pond st
u—
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
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 all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
i
c� Commonwealth of Massachusetts
r- Title 5 Official Inspection Form
'l I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readin s, if available last 2 ears usage NA
9 ( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NADate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
�- _ p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond st
u
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville. Ma. 026556 6-16-20
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:
6-16-20
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 650 gal
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
r
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.............. 77 Pond st
u
Property Address
Colleen Gallagher
Owner Owner's Name
information is Osterville Ma. 026556 6-16-20
required for every
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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 77 Pond st
V�
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
�n I? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Pond st
V�
Property Address
Colleen Gallagher
Owner Owner's Name
information is Osterville Ma. 026556 6-16-20
required for every •
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
1
Dimensions:
Scum.thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
U-
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information cont.
Y (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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�. : Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osteryille Ma. 026556 6-16-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):.
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length:
1-26'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e � 77 Pond st
u�
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. CitylTown 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.):
1 C pool with 1 out to trench cover is 4" below grade
i
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
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
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
In, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
77 Pond st
V
Property Address
Colleen Gallagher
Owner Owner's Name
information is 1
required for every Osterville Ma. 026556 6-16-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
F
77 Pond st
Property Address
Colleen Gallagher
Owner Owner's Name
information is
required for every Osterville Ma. 026556 6-16-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. � 77 Pond st
V,
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12'+
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:
Plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 Pond st
V�
Property Address
Colleen Gallagher
Owner Owner's Name
information is required for every Osterville Ma. 026556 6-16-20
page. Cityrrown 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Nplitation for 30isposal 6pstem Construction 30prmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(( ❑Complete System ❑Individual Components
Location Address or Lot No. —I l '(POND 57- o S y n Owner's Name,Address,and Tel.No.
CLtz,46-91Y4 o`VC-jL_
Assessor's Map/Parcel I g (,1 vZ —I iL 46
Installer's Name,Address,and Tel.No. S'®$—L}7 7-21817 Designer's Name,Address,and Tel.No.
CAf5wM 6 �l.�f—'�`Z 1ST$' I—A4ASi4Pt NIA
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 04 AAA)bC9 klj�"���G�
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 by this Board of Hea
Signe Date L
Application Approved by Date �" 7 1 (✓p
Application Disapproved by Date
for the
h followingre
asons
reaso
Date Issued Permit No.
r e
No. G - ' FeeDL
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
,d
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplicatlon for bisposal 6pstrm Construction jermit
,Application for a Permit to Construct`( ) Repair( ) Upgrade( ) Abandon(N ❑Complete System ❑Individual Components
`Location Address or Lot No. '7'-1 (700b 5 T 0 S`T. Owner's Name,Address,and Tel.No. �
Assessor's Map/Parcel a. -7-1 1>00b ST 0 S 1 LZC—
Installer's Name,Address,and Tel.No.Sob-Lt7 7-2817 Designer's Name,Address,and Tel.No.
(�AV6 a G� C Are l Sar S L-L Sr s P NIA
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
'Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 13AMI 2 k]
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 by this Board of Health. /
Signec Date
Application Approved by Date 7 ~�
A.
' Application Disapproved by Date
-for-the following reasons
ti� 1
Permit No. Date Issued
------------------------------------- ---------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO gERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned )by (_�IQ QT—cl yc„� { �1�'�
r at 7 7 kn tj Z) ;SrR�' _'a:STCN y!c L has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoPO4 ^/3a�'dated b
InstallerC, PGWWW6 &J7&?P,c_f9e—K LC-C, Designer lUl•4
#bedrooms Approved design flow /v+'7 gpd
The issuance of thi permit s all not be construed as a guarantee that the system will function design .
Date �]��/1(, Inspector 12�
------------- ---------------
No.2 G/ r`, — Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Constrnttlon permit
Permission is herebyanted Upgrade to Construct Repair U
�• ( ) P ( ) Pik' Abandon(
System located at 7:7 POND 5T e cD- !S7r
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 special conditions.
e
Provided:Construction must a co ple d within three years-61f the date of this ermit.
Date Approved b
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Date:
- 6-4-14
2644DH 2644DH 3068 2644DH Revisions:
6-26-14
14'-4" Finals:
t
38'
4
FIR51 FLOOR PLAN PROPOSED scale: 1/4=1-0
Y BUILDER TO CONFIRM ALL
CONDITIONS 20
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MEA5UREMENT5 5UPERCEDE 5CALE
Beth O'Neil BETSY(c1BET5YLAUGHTON.GOM
Additions Renovations Custom Homes
a 11 Pond Street
•
�! Osterrille, Massachusetts Basement rand Kitchen 508-272-5614
Renovations