HomeMy WebLinkAbout0127 POND STREET - Health 127 POND STREET -
Osterville
A = 118 — 117
a�
,f
iMa
Sep 24 2015 2022 Jim The Inspector Man 5085349919 page 18
i I
( D n
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' `ta
t 127 Pond Street M
Property Address
Audrey Killion
Owner Owners Name '
Information is
required for every Osterville MA 02655 9-19-15
page. Cityrrown State Zip Code Date of Inspection '
rx�I
Inspection results must be submitted on this form. Inspection forms may not be altered In any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms / //�� " OF A&pr
on the computer, `�������St10F7NA �p 11.1-
use only the tab 11.
1_ Inspector: -�����I-
..........r
key to move your
cursor-do not James D.Sears �� JAMES ,
use the return Name of Inspector ammmo
g ��
key. Capewid Enterprises,LLC %* *_
Company Name TTF��O��F
153 Commercial Street i,�h'�/F s I N SP \���
Company Address
a�a Mash pee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am.a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9-24-15
pector,s Signatwe Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer,if applicable, and the approving authority.
""This report only describes conditions at the time of Inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
(Sins•W13 Title 6 OfRdal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
AO 9td VS
Sep 24 2015 20:22 Jim The 'Inspector Man 5085349919 page 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
Information Is required for every Osterville MA 02655 9-19-15
page. CitylTown State Zip Code Date of Inspection
B. Certification (cony.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D,
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 16.304 exist Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal. Tank D Box and two chambers.
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
' 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):
t6irn•3113 Title 6 offidal Irspection Form:Submafece Sewage olsposal System-Page 2 of 17
I
Sep 24 2015 20:22 Jim The Inspector Man 5085349919 page 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
information is required for every Osterville MA 02655 9-19-15
page. Cityrrown State Zip Code Date of inspection
B- Certification (Cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired..
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation Is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Hoard of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines In accordance.with 310 CMR
15.303(1)(b)that the system Is not functioning In a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Tma 5 Official Inapectlon Forth:Subsurface Sewage Disposal System•Page 3 of 1T
Sep 24 2015 20:22 Jim The Inspector Man 5085349919 page 21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
information is required for every Osterville MA 02655 9-19-15
page. CWTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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 mwspW is less than 6"below invert or available volume is less
than %day flow/%ER elll.#vg
t5ins-3/13 Title 5 official Irsspedlan Form:Subsurface Sewega Disposal System•Page 4 of 17
Sep 24 2015 20:23 Jim The Inspector Man 5085349919 page 22
Commonwealth of Massachusetts
OEM
Title 5 Official Inspection Forme
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
information is required for every Osterville MA 02655 9-19-15 '
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El ® 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.
El ® Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well Water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure:
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ .the system is within 400 feet of a surface drinking'water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
15ins•3113 Tide 5 official Inspection Form:Subsurface 5"age Disposal System•Pape 5 of 17
Sep 24 2015 20:23 Jim The Inspector Man 5085349919 page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
Information is required for every Osterville MA 02655 9-19-15
page. City/rows 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 WA)
® ❑ _ 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 1he 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): 3 Number of bedrooms(actual): 2
DESIGN Flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):. 330
tSins.3/13 Title 5 Official Inwechon Form!Subsurface Sewage Disposal System•Page 6 o117
Sep 24 2015 20:23 Jim The Inspector Man 5085349919 page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
127 Pond Street
Property Address
_Audrey Killion
Owner Owner's Name
information is
required for every
Osterville MA 02655 9-19-15
page. CltylTown State . Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal.Tank D Box and two chambers
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑,Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings,if available last 2 ears usage 2013-49,000Gais
( y g (gpd)) 2014-76,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions: {
h Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(9Pd)
Basis of design flow(seats/personstsq.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:
Wns•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17
Sep 24 2015 20:23 Jim The Inspector Man 5085349919 page 25
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
Information is required for every Osterville MA 02655 9-19-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑. Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous Inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ina•3113 TNIa 5 Offldal Inspeodon form:SuCsurlace Sewspe Disposal Syslarn•Pape a d 17
Sep 24 2015 20:23 Jim The Inspector Man 5085349919 page 26
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Q FA
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner Owners Name
requiredfo I5 Osterville MA 02655 9-19-15
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
2000 Permit#2000-464
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"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.):
Pipsing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 16"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes- ❑ No
Dimensions: 1500 Gal. Precast H-10
Sludge depth: 1��
15ins•3173
Tide 5 Olfitlel Inspection Form;SubsuAece Sewage Disposal System•Page 0/17
Sep 24 2015 20:23 Jim The Inspector Man 5085349919 page 27
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street -
Property Address
Audrey Killion
Owner Owner's Name
Inforrequired tion
a Osterville MA 02655 9-19-15
required for 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
29"
Scum thickness OP
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and inlet cover at 16"below grade wbutlet cover at 9". In and outlet
tees. No sign of leakage or overloading.
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 '
15ins-3113 Title 5 Official kupection Form:Subsurface Sewage Disposal System Pape 10 of 17
Sep 24 2015 20:24 Jim The Inspector Man 5085349919 page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r� 127 Pond Street
Property Address
Audrey Killion
Owner Owners Name
Information is
required for every Osterville MA 02655 9-19-15
page. City/Town State Zip Code Date of Inspection
D. System Information (Cont.)
Comments(on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene• ❑other(e)(plain):
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
151ns•3l13 Title 6 Official hupectlon Form Subeurlace Sewage Dispoeal System•Pape 11 of 17
Sep 24 2015 20:24 Jim The Inspector Man 5085349919 page 29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner owners Name
information is required for every Osteryille MA 02655 9-19-15
Page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box Is Black Plastic 11'xl 1"-27". Below grade w/2 lines out. Box is clean. No sign of solid carry
over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
'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:
151ns•3113 Thle 5 Official Inspeaon Form:Subsurface Sewage Disposal System•Page 12 of W
Sep 24 2015 20:24 Jim The Inspector Man 5085349919 page 30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
° 127 Pond Street
Property Address
Audrey Kilion
Owner Owner's Name
information is required for every Osterville MA 02655 9-19-15
page. Cityrrown State Zip Code Date of Inspectlon
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two 500 Gal.dry well chamber's w/4'stone on side's and ends.2'stone between.
chambers at 28"below grade w/cover at 10".Chambers are dry and clean.Wall's like new:
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
t6ms•W3 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page f 3 of 17
Sep 24 2015 20:24 Jim The Inspector Man 5085349919 page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 127 Pond Street
Property Address
Audrey Kllion
Owner Owners Name
information isequired for every
Osteryllle MA 02655 9-19-15
page. Citylrown State Zip Code Date of inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).-
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Wins•3113 - Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 or 17
r
Sep 24 2015 20:24 Jim The Inspector Man 5085349919 page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Properly Address
Audrey Killion
Owner Owner's Name
information is required for every Osterville MA 02655 9-19-15
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
EAR B
3-4 ZECK
r
3 �
a
� o
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 15 or 17
Sep 24 2015 2024 Jim The Inspector Man 5085349919 page 33
Commonwealth of Massachusetts
EB NOW
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Property Address
Audrey Killion
Owner Owner's Name
information is required for every Osterville MA 02655 9-19-15
page. Citylfown state Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth hi h round water: g�+
P 9 9 feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record r
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 flow you established the high ground water elevation:
Auger T.H. 9'no G.K. Bottom of chamber's at 5'below grade. Bottom of chamber's at 4' above
T H Depth
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
iSlns.3113 Title 5 Offidal Ingrec ion Form Subsur'ace Sewage Dlaposal Syasm•Page 16 of 17
Sep 24 2015 2025 Jim The Inspector Man 5085349919 page 34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
127 Pond Street
Properly Address
Audrey Killion
Owner Owner's Name
Information is required for every Osterville MA 02655 9-19-15
page. City/Tom 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
15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17
TO BARNSTABLELOCATIONA2 2 ®�7OF
S SEWAGE#000—
VILLAGE 09 ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY \\ i
LEACHING FACILrrY: (type) /� )% S7�t� C��cam ) r,
NO.OF BEDROOMS ;.
BUILDER OR OWNER
PERMITDATE: 1110o COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching-Facility (If any wells exist
on site or within 200 feevofleaching facility) Feet
Edge of Wetland and Ldaching Facility(If any wetlands exist
within 300 feet of leaching facility). Feet
Furnished by—
o
o. o
o h-e �9
40
a
N �
(h
ah
�i
Al
N. Fee �r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zfp#,tication for 0iop-ozal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 7 Owner's ame,Address I
Assessor's Map/Parcel ,r 7
Installer's?kme,Adqrey,,and Tel Designer's Name,Address and Tel.No.
� C�atSrv-e��
Type of Building: st
Dwelling No.of Bedrooms -� Lot Size sq.ft. Garbage Grinder( 0,
• Other Type of Building No.of Persons —Showers( ) Cafeteria( )
Other Fixtures
Design Flow 2.90 gallons per day. Calculated daily flow � gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. —✓'"
Description of Soil
Nat re Repa' or=nswer when licable) K1 a s
Date last inspected:
Agreement:
The undersigned agrees to ens etion and maintenance of t afore described on-site sewage disposal system
in accordance with the provisio of Title 5 of the ental od n of to place the system in operation until Ce fi-
cate of Compliance has been i sued t 1* o t . i D
Signed Date Z
Application Approved by '' Date 7'
Application Disapproved for the following reasons
Permit No. Date Issued
———————————————— —— —————————————————
,`
No. t�j' Fee A*7< &:a
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es y
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
/ ."�-Zlppliratton for Mtgool *potem Cone;tru>rtion Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. .'� p Owner's Name,Address No` r
Assessor's Map/Parcel c ///7 _74 00 S 1! r Q fU
Installer's N We^,AddpressA,and Tel.No,. Designer's Name,Address and Tel.No.
l .
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder
Other Type of Building ees , No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow al gallons per day. Calculated daily flow 'D Q gallons.
Plan Date Number of sheets Revision Date
Title _"
Size of Septic Tank -, 0 Type of S.A.S. c-.P -,.SDO
Description of Soil
. N Rep 'rs or Alteratio s(Answer when plicable) 0
4�Date last inspected:
Agreement:
The undersigned agrees to ensure,the-canstraiction and maintenance oft e afore described on-site sewage disposal system
in accordance with the provisio o Title 5 of the ental od n not to place the system in operation until Ce ifi-
cate of Compliance has been issued this Be o t
Signed Date
� O�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued d
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(fertificate of Compliance
THIS IS TO CE t t e-On- to S age D sal System Constructed( )Repaired)Upgraded( )
Abandoned( )b
at has been constructed in accordance
with the proms s.of tl�5 an�fi Disposal System Construction Pe • MZ" 4 dated 9'- 7',215d<*
Installer _ Designer 6_,--0-
U
The issuance of this pe •t h 1 of e c nstrued as a guarantee that th s�, � wi�1 fun do •as sig
Date Inspector /D /!/1 �C
_ V
No. qor Fee �✓U�/r1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
1=igpoga1 *pgtem Construction Permit
Permission is hereby granted to Cp tru4 tlf )Re�paiir(X))U grad ( ) don( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this t.
,r� Gls 4�
Date: { � .� Approved b ,
1/6/99
NO'F �CE: "Clilt) Ibrih GIs To I:;e �.1-rsed Foil.t de Repair Of Failed
S'epI;. S"'steflis Onl;
CEh'l[IFICATION OF SKETc-Bi AND A2PLICAT10N.FOR A DISPOSA
W J-l%.S CONE _fUUCTI0N"f!,RMIT (V{WITHOUT L ESIGNED ?L,ANS)
- hereby'`certify that ho applicatio•:1 for.�isposal • orks
constnii tion pe:.-mit sigiied by me.dated _ _ , r /r.,ceming the`
ro c-t, .located at �. N
p p y __.1�__ meets al of the
-17
follov/ing cnteda. ;
N
• 71 e:.'ailed.yster i is :onn(,cted to a zesidential'dwelling only. 'Che a are no commercial or bus:ness
-�:;s�ssc:.fated v zth the dwelling.
+�• "1 soil is classillcdlas CLASS I;.Lirl the percclation rate is less,thin or egwl to 5 minut-.;per inch."
a
ri• Tae.--are no wetlands within-IN'feet of the p.r;)posed se)tic s.y,,tei.i
Vd, There;are no prive wells wit) n 30 feet of ] e proposed sep.i s)st.em
t� • Tliem is no in,.,. se in 11ow and/oi'change m s,propos,d
ti• Tl;c;r,are no`,variances iequestedbr needed.
t' -
�• Tl"e tottom of erhe pr leaching facilit) W'� ;ic't be locat(c"ie�s than five feet above the
m:ixLnum ao;bsted y J�undwater.table eleval ion. .�.djust the€i ii i.dwater table using the Friraptor
mehodwhenarplicsa'el: 1
A/• If the S.A.S. 1 411 be locat.d wrth`250 feet of an/vegetated well nds he bottom of the proposed
le.,-ring fa:.iiity will not be locafed less than fcurteen(14)feet above the maximum adjusted
1,1.u.:dwa;er tabi s el(vation,
1':teat:complete"'Il 'tollowrn
Top of.GcourA Surface s.txvation(using GIS infc rmatio"n.
)
B?) G.W. E:,cw4 ion. _ the MA}. Hi h G.W. Ad:i stn.e tit. 45
}_
t' IIIFFEREN:c BE iIVEEN
SP 114 DATA::
[S".w h propo sed Ph o.:..system'onback].
q:health f Ader.cent
`v v
p
`V
� O
'Irk
t
a�
TO OF BARNSTABLE //
i
LOCATION �� �0 ri SEWAGE # 0 '�L
VILLAGE ®S � � ASSESSOR'S MAP & LOT
--#?" 0
I •-
i INSTALLER'S NAME&PHONE NO. `l- , Pv a svz= V
SEPTIC TANK CAPACITY rJ 00
- I \
LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER OR OWNER ALIAX,26V
PERMTTDATE: U COMPLIANCE DATE: Lan
Separation Distance Beaeen the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
:: . Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
I' ;-.Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of'leaching facility) Feet
Furnished by
E 0;)
EO 01
L.
bb ,z
I
44
j rJ t; `L J O %4 tS