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HomeMy WebLinkAbout0136 POND STREET - Health 136-POND STREET, OSTERVILLE _ A= 118 101 J I� r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street - Property Address Spencer Macalster ' Owner Owner's Name/ information is Osterville ,V MA 02655 7/22/2020 required for every . - page. City/Town State Zip Code Date of Inspection r r 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 filling out forms A. Inspector Information 454 on the computer, use only the tab Jason Haskell key to move your Name of Inspector cursor-do not All Clear Septic&Wastewater Services use the return Company Name key. 102 W. Main Street � Company y Address Norton MA 02766 City/Town State Zip Code 508-7634431 S113520 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 (310 CMR 156000); 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 l have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4 4. ❑_ Fails . /W July 30.2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 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: Septic tank, Leech Pit. Septic tank and all related components are in working order. SYSTEM PASSES 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 &Massachusetts VTitle 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments ;mow 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): El 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 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) . ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ .The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 , 7/22/2020 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 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 ® 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary,(cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for aH inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ®_ ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 410 gpd 9 ( Y 9 (gpd)): Detail: ° Property has irrigation Sump pump? ® Yes ❑ No Last date of occupancy: Currently Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owners Name information is required for every Osterville MA 02655 7/22/2020 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: 2015 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. Citylrown 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): Septic tank, SAS Approximate age of all components, date installed(if known)and source of information: 8/29/05 Per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 27,. feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints good, no leaks, vented. t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster,. Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. City(fown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 15"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: 8'3"x5'x5' Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 26" - Scum thickness off 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 19" How were dimensions determined? Rod&tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time, Baffle's&Tee good, Liquid is at outlet invert, no evidence of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions:. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 4 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 n ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes El 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 NO D-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.): t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 12 of 18 l Commonwealth of Massachusetts ig Title 5 Official Inspection Form ' f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. Cityfrown 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.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑, leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil and Vegetaion normal, No signs of hydraulic failure. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 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.): , 4 V t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 ' 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 1 t5insp.doc•rev.7126r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 AN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owner's Name information is required for every Osterville MA 02655 7/22/2020 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: 20'+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: a You must describe how you established the high ground water elevation: Previous T5 done 1/10/12, Property sits 20'+above Sam's pond. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Spencer Macalster Owner Owners Name information is required for every Osterville MA 02655 7/22/2020 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form.,Subsurface Sewage Disposal System•Page 18 of 18 1�_ 7/30/2020 20200730 131745.jpg { x y/ r i 57"T . w MT u; q Or dh y. https:l/mail.google.com/maiUu/t/?tab=wm#inbox/WhctKJVzZKVCTRWMmklkPbcOdhStyzjjlKLJXjGLWGxzgkggwZkMWrMeGggKPTXKwwTScB?projector-1&messagePartid=0.l 1/2 ► Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessment� I 136 Pond Street L[9 1)q Property Address l Sue&Warren Carstensen Owner Owner's Name information is required for Osteryille Ma. 02655 417/2008 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. Important:When filling out A. General Information 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 -.- P.O.Box 763 Company Address Centerville Ma. 02Q32 reR" City/Town State Zip jocle L (508)428-4028 S14454 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 3/17/2008 Inspector's'Sign&ture 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. 136 Pond St.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 t Commonwealth of Massachusetts + W Title 5 Official Inspection Form « Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Pond Street M Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont) Inspection Summary: Check A,B,C,D or E/always complete all of Section'D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. . Comments: - r 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 Healthy will pass. a Answer yes, no or not determined (Y, N, ND)in the❑for the following`statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 136 Pond St.•12/07 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 136 Pond St.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts - I Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for. Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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: I 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 Y2 day flow El ® 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. 136 Pond St.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 136 Pond Street Property Address Sue &Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 ❑ E] Area 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. 136 Pond St.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 • Commonwealth of Massachusetts s W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is Cisterville Ma. 02655 417/2008 required for 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? ® El 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)] 136 Pond St.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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 Seasonal use? ® Yes ❑ No Water meter readings,if available last 2 ears usage d 2006:4,000 g ( y g (gpd)): 2007:45,000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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): 136 Pond St.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osteryille' Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No t 136 Pond St.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is. required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10'+ p Pp y 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: 14" p g 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: 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 136 Pond St.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 �• Commonwealth of Massachusetts v. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every 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.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El.other(explain): 136 Pond St.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection D. System Information.(cont.) Tight or Holding Tank(cont.) 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 Distribution`Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert D-Box not present.--- Co mments(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): 3 Pumps in working order: , ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 136 Pond St.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code - Date of inspection D. System Information (cont.) - Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): r Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gl. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of podding,damp soil,condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching Pit was dry at time of inspection.Stain line was 34"below invert pipe. 136 Pond St.•12/07 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 15_ I . �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 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.): 136 Pond St.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® Zoom OutIn a i .aa , .1 a ^ a iq. i d t l 5 a 5 tit BSI r S e , 4•` 0 20 Feet Set Scale 1" = 20 I Aerial Photos (`nn„rinhf )nnr,9nn7 T—n n/Rornefahlo KAA All rinhrc roconn http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=118101&map... 4/21/2008 I . � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond Street Property Address Sue&Warren Carstensen Owner Owner's Name information is required for Osterville Ma. 02655 417/2008 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 LP 20' 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: As-Built Card ❑ 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-OQO-01 plate#2 annual ranges of ground water elevations. 136 Pond St.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 l Town of Barnstable Regulatory Services BARNSTABM ; Thomas F. Geiler,DirectorMAM _ Public Health.Division A�fp MAy A ' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report;this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. OWN OF BARNSTABLE LOCATION / 6 m2 SEWAGE# �a VILLAGE S ASSESSOR'S MAP&LOT &PHONE NO.4 . SEPTIC TANK CAPACITY ��: G� . LEACHING FACII.TTY: (ty -= TP' (size) NO.OF BEDROOMS y` BUILDER OR OWNER PERMITDATE: '" COMPLIANCE DATE: ,C Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe9kof leac ' i. Feet Furnished O , Z y + , o i Fimic .. . .. .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH V4�....----.OF...... 4pliration for Bifivviittl Marko Totistrurtion Prrutit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal System at a - ---� , ------ -------------- -Ass 1 l r Lo Owner Address e Nss-••--- —_____________ A ----------• - o d O Installer Address Type of Building Size Lot............................Sq. feet 0-4 Dwelling—No. of Bedroom -----------Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Build in o.� of persons____________________________ Showers ( ) — Cafeteria ( ) � Other fixtures .______ �� ----------------------- Design Flow_ ____________________________ gallons per person per day. Total daily flow____-________ _. W �-----•-----} ­/-------------- W WSeptic Tank I Liquid capacity ji (!gallons' Length________________ Width..... -_....__._ Diameter---------------- Depth-______-___-.-- x Disposal Trench—No. ________________ Widlh___._._____*en Total n�t1 ,__.___ .._;_..___ Total leaching area___.________________sq. ft. Seepage Pit No-__________I__ `/ b q Diameter____ _ _________ elow inlet_____._.____________ Total leaching area-__-________--____s ft. z Other Distribution box ( ) Dosing tank ( ) _ aPercolation Test Results Performed by.......................................................................... Date------------------------------------ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water---.______________--.--- fq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------�------- ---------=---- ---------------- ......................................................................................................... O Description of Soil................. . r..._... ------------------------------------------------------------------------------- x V ......................................................................................................................................................................................................... x ----------------------•--______..:---------------•-•---------••--.__-•------------ -------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------;--------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gned---- -• __ ___________________________•---______._-----_._•------------------- D to Application Approved BY ______ __-- - - � � Date Application Disapproved for the following reasons-.......................... -•--•---------•-----------------•------•----•-•---•-------------------- ..-•------------------------------------------•-----------------•------------------------------ Date PermitNo......................................................... ' Issued--•------------••------------------... Date No...... $.. ..... Fick.....2................... THE COMMONWEALTH OF MASSACHUSETTS BOARD - F HEALTH --- ---_------------_------ -----------OF...... ...? Appliration for Rapo at lVerho Tonstrurtion rjerniff Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage.Disposal System at NT ._. M.&__ r ..i ................. ------_�_� ...._,�.� �._.......--_ .............. J caUSn-Ad ress or Lot No. E Owner 14141---------- - .0 -----------------•-------------------------------------•-- Installer Address Type of Building Size Lot........................._Sq. feet Dwelling—No. of Bedroom'__.r_______________ --------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Buildin� yp �'__� .1'�__-- ,�°��o. of persons............................ Showers ( ) Cafeteria ( ) Otherfixtures ---------- --- ......................-----------•---•-- ................-••--------•---------------------•-- w Design Flow............................... t..gallons per person per day. Total daily flow------------- . • *.__ _________gallons. WSeptic Tank-� Liquid capacity/ ".gallons Length................ Width................ Diameter----------------- Depth................ x Disposal Trench—No_____________________ Width....... = __. Total-j-,ength ...._. ......... Total leaching area--------------------sq. ft. �f Seepage Pit No____________ ______ Diameter../ `t : 9M�k610 +nee _..... Total leaching area-___-_-.-_--:----•sq. ft. z Other.Distribution box ( ) o Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date-------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water--------_____-__-----.-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------._ -------- O Description of Soil ....... ............................................ x U -••-•--------•-•-•-•------••-----------•-------•------•-•----•-•--•-•--•---------=--•.............•----•----•----------•-•----------••-•------•••--------------••---------------•-•-•-•-••-•------------ w VNature of Repairs or Alterations—Answer when'applicable.--___-•---------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------•----------------•-----•------....------------------•-•--•-----------------••-•-•-•.....----------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned ---- --------------------- ------------------•------------ Application Approved Bte Zate Application Disapproved for the following reasons:----_-_----------------- ......._....--------------•-•---••-•----------••-----••---•---••---------- -------••-•---------••---•---------------------------•------------•-•-----••--------.....----•-•••--•-•-•-------------•--•-----------------•--------•-•--------------••••------ Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �- 4d4 OF...... .............. C'er#if irtttr of Tontphattre T� IS I TO CE IFY That the Individual Sewage Disposal System constructed (For Repaired ( ) u by.... Oil� ) ` ` - ------ -- ------ at... . .. ........�C___._F ._� __-_ _-_------ � 5 leY } 4f has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descr))ed in the application for Disposal Works Construction Permit No........... .7:4............. dated.... _ .. ;(�77._L'5L...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUE® AS A GUARANTHAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------------------------------------------•r-----------_.... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r^ ` f , ...... �- No. ..... � �.........of - ------------------------- FEE.- ,. Bbvm at orkii ni#rurfivn prmit Permission,is h eby granted +~ ==- =, .................. to Construct (1 or ' it ( Pan .Individu ew � +-sa ' s em at 9. I ------ Street. ----- as shown on the application for Disposal Works Construction P nut Nc Dated__',,_-).. ------------- B and o'Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(ooutiuued) ProPertyAddrww 136 Pond Street Osterville,Mass.' O=er. Jack Slocomb Date.of Impeotiou: 7 $ 9 Ej SEETCH OF SEWAGE DISPOSAL SYSTEM. • include ties to at least two permanent referene"landmarks or benchsuark. locate all wells within 100' Centerville, Osterville Marstons Mills Water Company -66 Mod EPTH To GROUNDWATER pth to pound water: t feet r . iOf detarmiaatioa or approxima S z rx Revised 11/03/95) 9 wt c.. x COMMONWEA iTH OF MA.SSA..CII USETY- I)EPA,ITI�'IENT O ENVIRONMENTAL P]R. )TE �T : BE IT. R.NOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications _as required. and is hereby authoriz_1d to use the title CI I=_TIEIED TITLE 5 SYSTEM* INSPECTOR as rovided hi ' 1C CMR 15.3�0 and Section 13 of Chapter p C e-_eral Laws- _ ss_sed by The Dc:.partment of Environmental June S. 1995 _.._...._ _._.._.._..__.. Acting Director of the 'ion of Wa c' l 117 OR HOLDING TANK�N41 rf (locate on site plan) Depth below grade:NIP , Material of ooastnution:N/?ooncrste metal_FRP—other(explain) N� Dimensions:_ n1�Q Capacity: ns Design flow:_ iA ¢allons/day Alarm level:_ Comments: (condition of inlet tee,condition of alarm and float switches,etc.) J � DISTRIBUTION BOX:./1 41'2. (beats on site plan) Depth of liquid level above outlet invert: 44 Comments: , (note if level and distribution is equal,evidence of solids over,evidence of� � leakage into or out of bar,etc.) PUMP CHAMBER::L/eAZ (locate on site plan) Pump+in working order:(yes or no)_� Comments: (note condition of pump chamber;Condition of pumps and appurtenances,stc.) (revised 11/03/9S) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C sys. ,rEM INFORMATION (oontinued) PropertyAddreas: 136 Pond Street Osterville,Mass. Owner. Jack Slocomb Date of Inspection: 7/8/9 6 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) o If not determined to be present,explain: leaching pits, number: i leaching chambers,number leaching galleries, number: leaching trenches, number,length:�leaching fields, number,dime ions: overflow cesspool, number: nts: ( to co tion of soil, igns of hydraulic failure, level of ponding,condition of vegetation,etc.) e llum o fine sand;No signs of hydraulic failure•No signs of ponAil in . vegetation is normal. WJ6 jr fj9Alr,s n)C:E; t_ 4T _ __f- CESSPOOLS:/ I✓� (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(owspool must be pumped as part of inspection) Commgnts•�(note oondiiti'on$soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 1i� (.pJY12d�L�i PRIVY: �� (locate on site plan) Materials of construction: Dimensions: Depth of solids: �1�� Co nth(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) L�s��irl7 S (revised 11/03/95) 8 No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Aes� pplicatton for Migogar *p5tem Con0tructton Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon�6 ❑.Complete System ❑Individual Components Location Address or Lot No. 13(d 190 a,04 5 rrGeT Owner's Name,Address,and Tel.No. W A(rrG111 Assessor's Map/Pamel jj6 j O gam."'tt C Installer's Name,Address,and Tel.No. �'''P ' �`f�'I'aO�j�f Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Z Lot Size 4 s 1000 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) ( 6"i'l L .tnd L sL 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 Boar ealth. Signe Date Application Approved by Date Application Disapproved by: .. Date for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTSEntered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pphratton for �Dtgpogal *pgtem Con0tructtlon Vermtt, Application for a Permit to Construct O Repair O Upgrade O Abandon V ❑.Complete System ❑Individual Components Y. 4 - Location Address or Lot No. /'c, Pond 5 art T- Owner's Name,Address;and Tel.No. fit/1�rrG✓i G �/4'n S e� Assessor's Map/Parcel. Installer's Name,Address,and Tel.No. `'rye" �° �"f.���a�j Designer's Name,Address and Tel.No. \� (la, Yali rof 't/ riser t Type of Building: Dwelling No.of Bedrooms Lot Size S,Oou i sq.ft. Garbage Grinder ( ) Other Type of Building S�Z , {�l1YA;. No.of Persons t 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 6PS A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ( c�ilsi � ray !,r (�4���M ) L e"iL Date last inspected: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation-until a Certificate of Compliance has been issued b this Board�o ealth. P Y i i -Z S Date ne `i g Application Approved by / _ , Date ' Application Disapproved by: Date for the following reasons ` Permit No. Date Issued ——————-———————— ——————————————————————————-- THE COMMONWEALTH-OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtftcate of Comphance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned;(.,_)by j1,0 , G . at 4j fP 5 f"en i tA.- has been cos ted ordance P P Y with the provisions of Title 5 and the for Disposal System Construction Permit No. dated v� Installer „R ,�,y�a C . �nr,3-eS Designer #bedrooms Approved design flow gpd The issuance of this permit shall of be construed as a guarantee that the system will f� u cttion as-de igned. Date �, �" Inspector � ——————————————————————————————————————————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS t w0tgpogal *pgtem Congtrurtton J)ermtt Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ` _ System located at 3 �I'ri.-f-T 0SrtN .1 t e 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. ti Provided: Constructio t b�co leted within three years of the date of this N. Date _ Approved by . 0 OWN O;F BARNSTABLE LOCATION SEWAGE # '�� VILLAGE �� —ASS ESSO 'S MAP&LOT &PHONE NO.---,) SEPTIC TANK CAPACITY LEACHING FACILITY: (ty 1` __>_e_ . (size) G� NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: , Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe of lead' i _ Feet FurnishedS S7- psT Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for every Osterville Ma 02655 1/10/2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information I n on the computer, use only the tab 1. Inspector: J key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. C y e Enterprises � Company Name .153 Commercial St. Company Address Mashpee Ma. 02649 Cityrrown State Zip Code 508-477-8877 SI 4522 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 1/10/2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board r 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 thesame or different conditions of use. t5ins•11/10 Me 5 Official brspedion Form Subsurf�aoa t go Disp System• age�1cf�17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012. every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described, in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of.Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. Cityrrown 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 i ❑ 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 r 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. Citylrown 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 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? ® ❑ 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 Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•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 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. City/Town State Zip Code bate 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 -Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2010=31,000 total=85 gpd 2011 = 0 total gallons Sump pump? ❑ Yes (D No Last date of occupancy:. unknown . Date Commercial/industrial Flow Conditions: - Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/1.0/2012 every page. Cityrrown 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: 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 r , ❑ 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 = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. CityrTown 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 E No Building Sewer(locate on site plan): Depth below rade: 1.5 p g feet - 4 Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line:• 1 feeett Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage,vented through roof' Septic Tank(locate on site plan): • Depth below grade: 10"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: 1000 gallons Sludge depth: 5" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 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 3.5' 21- Scum thickness Distance from top of scum to top of outlet tee or baffle 6' Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact and in good condition. 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 J i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. Cityrrown 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 r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Cisterville Ma 02655 1/10/2012 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.): No d-box 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 x 1000 gallons ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): The leach pit was found to be dry at the time of inspection with a stain line approx 24"from the bottom. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. Cityrrown 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.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 136 Pond St Property Address Warren Carstensen Owner Owners Name information is required for Osterville Ma 02655 1/10/2012 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface;water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ 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: The property overlooks Sam's Pond is is elevated considerably. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osteryille Ma 02655 1/10/2012 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 , 1/10/2012 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 a • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is Osterville Ma 02655 1/10/2012 required for every page. Citylrown z State Zip Code Data 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 pprrn, 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 Y day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 136 Pond St Property Address Warren Carstensen Owner Owner's Name information is required for Osterville Ma 02655 1/10/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No E , ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins"11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 DATE: . 7/8/96 r . 136 Pond Street ✓ u( Osterville,Mass. sAF 1. 6Iy 026554° ` On the above date, I Inspected the septic system at the above Address, fe Thls system conslsts of the following: 1 . 1-1000 gallon septic tank. 2. 1-1000 gallonleaching pit. Based on my lrltqrk ctIon, I c6rtlty the following cohditlons: 1 . This is. a title five septic system. ( 78 Code ) 2. The septic system is in proper working order at the present time. COmpany:_J. P_riak�oulber a on- 'Inc --- ------ . Address I31�a-- i6—__---" -- ---_-"1-1 L L1tas� ' •02G32 Prone: ( THIS CFI ± DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. tp',ACOMBER & SON, INC. Tank 4 0e sjPools-Laachflelds Pump .d &. Instilled Town Seiver..Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 Office of En'v':ron 71en101 Affairs -- - n � 41�Cc y, 7,o rnenzal Protection real, °r F. Trudy Cox* avid B.struhs ConvWWorw SUBSURFACE SFV'A(:E 016POSAL SYSTEM INSPECTION FORM PrUtT A Lj C1.1 Fl CATI ON ProportyAddrosa: 136 Pond Street Oste'rville,Mass. Address of owner. Data of Iaspootloa: 7/8/96 (if different) Name of Inspootor. Joseph P. Macomber Jr. Company Name,Address and Telephone Nu:ntx r. J.P.Macomber & Son Inc. Box 66 Centerville,Mass.02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the rewaoe:diip;.rs) iy.-win at this address and that the information reported below is true,accurate and complete as of the time of inspoction. The inspa tioo w u ;n!;-fer u;rd ba:od on my training and experience in the proper function and maintenance of on•site sewage ddipoaal sy.teuis. Tho r}ct,:;n: �as.ccar Conditionally Passes Needs Further Evaluation By the 1 o App:vvine Authority Fails Iuspoctor's 9lgcnaturo ��, Date: " , I 4 The System Iaspoctor subinit a copy of this inspoction I !.,Qrt to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a desiZn ilow of 10,000 gpd or greater, the inspoctor and the system owner shall submit the report to the appropriate regional office of the Department of Enviroamontal Protoction. The original should be sent to the system owner and copies seat to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any intonation which i(ld-utic teat ti,: iyite:n NioL;,ea any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluatod a:e undicatoi , ;•: :. B) SYSTF—Nf CONDITIONALLY PASSES: 418 One or more system components nvv,: to be repL-,cv .;r red a rod. 11v system, upon completion of the replacement or repair,passes inspection. Indicate Y jno,or not determined(Y, N, or ND). Dascribo basis of dowru,i ation in all instances. If`hot determined',explain wbX not) The septic tank is metal, cracked, strvcturally unsound, shows substantial infiltration or exMtration,.or tank failure is imminent. The system will pass inspoction Lr the existing septic tank is replaced with a conforming septic tank as approved by the Board of Hea.th. (revised 11/03/95) One Winter Stroet 0 Boston, Massachuto.t: ;. i' : s FAX(617) 556-1049 9 Telephone(617) 292.5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Prop,ertyAddresa: 136 Pond Street Osterville,Mass. 02655 Owner. Jack Slocomb Date of Inspection: 7/8/96 B)SYSTEM CONDITIONALLY PASSES(continued) �IhGL° Sewage backup or breakout or huh static water level observed is the diaCibutwn:l>oz is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass nnapectioa if Health): (with approval of the Board of broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: oQo_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE F.NVIRONM EIVT: Cesspool or privy is within 50 feet of a surface water AW Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APfR—bVh ATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. �' The system hag a septic tank and soil absorption system and is within a Zone I of a public water suppy well. The system hag a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is Ion than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for conform bacteria and volatile orgazd compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) OTHER' Ay (revised 11/03/95) 2 _..... F.::.-:•;_�....-:a—r.::a••.-rnr.-n•r.::r:.:s.^�t.�-rnr—rt�s':+s.'s drerr5r��'+-T.csssr+s�rsrr.Ts .. tsmr TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 136_Pond Street Osterville Masa. ASSESSORS MAP, BLOCK AND PARCEL # OWNER's NAME jack Slnndmb PAR7' D - CERTIFICATION NAME OF INSPECTOR _ Joseph P.Macomber dr. , COMPANY NAME J P Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville Mass. - Street Town or City State Li: COMPANY TELEPHONE 1508 775 3338 FAX ( 508 ) 790 1578 R , CERTIFICATION STATEMENT' I certify that I' hR.ve -personally inspected the sewage disposal system this address and that the information reported is true, accurate, and complete as of the tirite of :inspection. The inspection was performed -and any recommendations regarding upgrade , maintenance, and .repair are consistent with my training and experience in the proper function and maintenance of or site sewage disposal systems i i Ili{ 1, Check one. System.PASSED The inspection whic'h. I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15, 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this forma Sys tem FAILED* The inspection whic,l;1: I have conducted has found that the system fails t( Protect the public liealth 'and the environment in accorda-tice with Title 5 , 310 CMR 15 . 303, an'j as specifically noted on PART C - FAILURE CRITERIA of this inspection forme Inspector Signature or Date 7/9/46 One copy of this certification must be provided to the OWNER, ,t}ie BUYER ( where applicable) and the DOARD OF 1iEAL1'1t. If the inspection FAILED, th-e owner or operator shall upgrade 'the aystem .within one year of the date of the inspection, unless allowed 'otherwise as provided in 310 Ch1R 15 .306 . or required partd.doc ;b f AM I have determined that the system violates one or more of the following failure criteria as defined is 310 CMR 15.503. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. , XBackup of sewage into facility or system component due to an overloaded or cloggod S _. Discharge or ponding of effluent to the surface of the ground or surface waters due to an Overloaded or clogged SAS or cesspool. 44 Static liquid level in the dretnbutton box above outlet invert due to an overloaded or clogged SAS or cesspool. AO Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, 10 Required pumping more than 4 times in the last year NOT due to clogged or obatructod pipc(s). Number of times pumped_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. /fLQ Any portion of a cesspool or privy is within a Zone I of a public well. 1Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. 40 Any portion of a cesspool or privy is.leas than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for ooliform bacteria,volatile o 'c compounds,ammonia nitrogen and.nitrate nitro n. . >� r6� Po 8e 8e , El LARGE SYSTEM FAILS: The following criteria apply to large jystenu in addition to the criteria above: _ The system serves a facility with a design flow of 10,Q00 gpd or greater(Large System)and the system is.a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply /V the system is within 200 feet of a tributary to a surface drinking water supply •- t the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please corwult the local regional office of the Department for further information.• (revised 11/03/95) 3 c SUBSURFACE SEWAGE DISPOSAL SySTEM INSPECTION FORM a PART B CHECKLIST Pt*P'ertyAddress: 136 Pond Street Osterville,Mass. B91wner. Jack Slocomb Date of Inspection: 7/8/9 6 • Check if the following have been done: �P Ping information was requested of the owner,occupant,and Board of Health. .None of the system components have been pumped for at least two weeks and the during that period. Large volumes of water have not been introduced into the enssystemc has been recei vmg normal flow ram system r eetttly or as part of this inspection. 2A.built Plana have been obtained and examined. Note if they are not available with N/A /The facility or dwelling was inspected for signs of sewage back-up. The system does no:receive non-sanitary or industrial waste Low , The site was inspected for signs of breakout. Y All system components,Zluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tees,material of conatruction, dimensions, depth of liquid,depth of sludge, P tank was inspected for condition of homes or depth of scum. ZTh,size and location of the Soil Absorption System on the site has been determined based on approximated by non intrusive methods. ezurting iafosmation or . The facility owner(and occupants,if different from owner)were provided with Surface Disposal System. information on the proper Per maintenance of Sub- i { (revised 11/03/95) 4 r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prolwaly,:.,- 136 Pond Street Ostervlle,Mass. U►v»er. Jack Slocomb Dale of Iraspou.;. . 7/8/96 RESIDENTIAL- FLOW CONDITIONS r Design flow: Number of bedrooms: Number of current residents::� Garbage grinder(yes or no): Laundry connected to system(yes or no): Seasonal use(yros or no):_ Water meter readiz,,p,if available: I ff �j1j a Last date of occupancy:7—"j� COMMERCIAL IA`DUSTRIAL•..1 Type of establishment: rl �f~ Design flow:. 7 ona/day Grease trap present: (yca or no)AAf Industrial Waste Holding Tank present: (yes or no)," Non-sanitary waste discharged to the Title 5 system: (yes or no)N.* " Water meter readings,if available: Last date of occupancy:Alff OTHER. (Describe)` /9 Last date of GENERAL INFORMATION PUMPING RECy=01 "io : ' :,u Pf information: System pumped as part of inspection:(yes or no) If yes,volume Pumped: Reason far pumpi:, /l//Q " TYPE 0 SYST .i Septic tau</ai!ia� ,ox/soil absorption system Single azsp;cl Overflow ccaspwl _ Privy � Shared system(yesnor no) (if y?sL attach jprev.ious ins n records,if an Other(e_Yl_._.>_�.�,o��•/$ .CA�i�. er Y1,,P '(.�!//�/�i'y APP .,;:ponents,date installed(if known)and source o!information:/ --J�Qa1.GNiy' .. Sewage odors d-Aacted wheii arriving at the site:(yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. .' SYSTEM INFORMATION (continued) (ropertyAddress: 136 Pond Street Osterville,Mass. i)wner: Jack Slocomb `)ate of Inspection: 7/8/96 EPTIC TANK:,LA04 ocate on site plan) lepth below grade:,_ if taterial of construction: t oncrete_,metal_FRP_other(explain) imensions• udge depth. istance from top of ludge to bottom of outlet tee or baffle:�6<< :um thickness: ,� istance from lop of scum to top of outlet tee or baffle: C� stance from bottom of scum to bottom of outlet tee or baffle,_.. - L.�. )mments: commendation for pumping, condition of inlet and qutletitees or baffles. depth of liquid level In relation to outlet Invert,str ctural vity, evidence of leakage, etc.) . Pum_p tangy 'ev r 2-:_ ..ln S Y outlet n. EASE TRAP. 4)dwl e- :ate on site plan) )th below grade:; erial of conslri�nion,�r�l;oncrete_,,,metal_FRP_,other(eicplain) tensions. AJ m thickness: ance from top u:scum to top of outlet tee or baffle:_tI-& ance from bottom n)srum in bonam of outlet lee or 6(lle:_ I& iments: mmendation for pumping, condil—n of'inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural rity, evidence of leakage, et ' -------------- ced 6/15/95) 6 r