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0142 POND STREET - Health
142 Pond Street A= 118- 100 Osterville ri N r! 4 No.... FEB.... ��...©�-- , THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .........................:----------.......O F....................................... Appliration for Disposal Works Tonstrnr$inln Prrutit Application is hereby made for a Permit to Construct .( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. i rl-------------•-----------------•------ ea_p�'...... .................'A' f B,.K.. jv�� ��,�I- I�g� t Owner Address A_ 'Gv.l.................................................. - --• .-..fP !y S ...... �-....---....----.... Installer . Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........Z-------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—TYP of Building/�,�cf-=--- e .c ����:fNo. of persons......... ................. Showers ( ) — Cafeteria ( ) a 04 Other fixtures ------•-----------------------------•--•---------------••-------•--•-••-. W Design Flow............................................gallons per person per day. Total daily flow:...........................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---............. Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------............sq. ft. Seepage Pit No--------------------- Diameter......--............ Depth below inlet........:........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. 1................minutes per inch Depth of Test Pit.--.--.............. Depth to ground water....---------........-:: fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----------------------------•------------•---••....------------.....•----••--••....--•-•-•-•-_--_................................... .... .----•....... ..-- 0 Description of Soil................................................................................................................................................-. ................ x U ..............•................-----•-•----••-------•----------------•-•----------•--.....-----•-----...------•-••-•---------------------------••--••---------•-•••••-••-•....----------•-------•-----... w U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..... ----•--•----------------------------•--•----------•-----------------------------•--•------......--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until=-ertificate of Compliance has been issued by the board of health. Signed----ArA-If- le_ -._....--- --•----•-�..k---------- - °Z s�----- a Application Approved By........ ------•-• ------ -ap.,� ate Application Disapproved for t following reasons-------------•---------•--------•------------•----------------------•.....--------------.......----•-......---... .............................................................................................................................................. ------ 4 -------------•----------..-Date-•----..._.._. Permit No._- .S. ._Z.4.-••----------------- Issued........ Z � " D to }' 4 No gg �_ Fps..`..?L............... � THE COMMONWEALTH OF MASSACHUSETTS .. BOARD OF HEALTH e ApplirFatilan.for Disposal Works Tonstrurtiun Permit Application is hereby madeyfor`a'.Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System it: .j-� �� — • - ....... ._.... ._.... .......................................... .....---------._...----•----......_-•-•-- Location-Address' r Lot No. J- + � llrrR�; C.'i4`vJJ..._6!-} - !:��y�!'!.✓..r''Ak.'5....---- rll.�}:t::a�,(-fg.tt/ rz� .. ............ { Owner Address --•-- ....� /..C�'....3 ........... r '' r -- Installer - Address Type of Building Size Lot............................Sq. feet Dwelling,—No. of Bedrooms......... ................................Expansion Attic ( ) Garbage Grinder ( ) a aOther—Type of Building �.Es.____ rt_l {:is No. of persons____________________________ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------••-------------------------- W Design Flow............................................gallons per person per day. Total daily flow----........................................gallons. W P .---••-•--••---- Width................ Diameter................ Depth................ xDisposal Trench—No ____________________Width_______,___•,_ �: Septic Tank—Liquid capacity_______.____gallons Length•_ Total Length.................... Total.leaching area........ ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.._...............sq. 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------------............. 44 Test Pit No. 2................minutes per Inch Depth of Test Pit.................... Depth to ground water........................ a ---•----•-------------------••----•------------------•---...------....__..__....._•••---••-•-•-••••••••-...---.............••----•-••••-•--•--....-----_----- Descriptionof Soil......=.................................................................................................................... `'---------•-- x ------------------ W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•--•---------------•-•--------•------•----------------.._..----•.:.....•••-•••----•-----•---••-----•-•-------•-•---•••----•-••-•••---••----•-•---------•••••-----........_. YS Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation u til a ertificate of Compliance has been issued by the board of health. Y Signed---- f... . Application Approved B tee Date Application Disapproved for a following reasons_________________________ "` ---------------------------------------- ----------•-•••----...._•--•-- .................•_.....-•-•-•---._._.._..---------------._...------------...--------...---•----.........._...:.._...----•-----------------------...-------------•-------------......................... r •' Date Permit No...... .. -----....--- - Issued•- - ate THE COMMONWEALTH OF MASSACHUSETTS „ BOARD OF HEALTH ..........................................OF.. .........:..............................._...._..... „? (Irrtif irtt#p of TuntpltFanrr THIS IS TO CERTIFY,*That the Individual Sewage Disposal System constructed or Repaired ( ) by. '' �T-r �' a 5-------------------------------------------------= ----------_____-------.:.__------.:........._.._........ ............... Installer at......... ............... .............&. .......................................................................................... has been installed in accordance with the provisions of TITLr, 5 of appl'ica.tion for Disposal Works Construction Permit No.____ age State Sanitarydated _Code a�described in the THEASSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1i .. i cde;J� DATE................. .` r�.. .�.................... Inspector---------..."._ ------- ____-••--------------------------- THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH '3S -67-4. ............................:..............OF...................................................................................... 1... ..........` ` No......................... FE� Disposal Works Tnntrudion truth Permission is hereby granted---A'!¢in ;c..... '.w -------------------------------------•--•--•-------.....--------....-•---.._..-•---....... to Construct or Repair" ) an Individual Sewage Disposal System at No.. ' 1.2 >��G ds d• - f!Ztfjvl lI.✓r`......_._._ � Streetc� y as shown on the application for Disposal Works Construction Permit Nc�.'____`i_.`_"__ Dated_______________ - -n ...... DATE............--•-•----•- -- FORM 1'255 A. M. SULKIN,^INC., BOSTON „ LOCATION SEWAGE PERMIT NO. VILLAGE Jz l �1� /, INSTALLER'S NAME , i ADDRESS rn &Z2 2 ra B U I L D E R OR OWNER rien DATE PERMIT ISSUED -� r DAT E COMPLIANCE ISSUED t-zz- � r f1 F STD 41i,o SCKE::L 'FAM14`(: 3 :6Cu12ooi`-� N u .GA IZC3KGC G ►`1 D C R_. - y p 4 Auo 40 3 i t--- D.A4LY : FLoW;..._.-.:[t d X 3 33'o G.P..p- 4� A: Zf, 1 , SEPTt c. 7AMK # :330 .X. 15670 ' 49.5 G.P.0 USG 100 0 L ..TA►J(C.. — 39 38' HD• D IS Po5AL p.rr V SE 1 o00 51DEWAU- ^RCA. ` 150 5. P. ' ►N(r n"' G. P. O � � 8• i ..K ),o _ So. G. P: D. 4 Z5-' e•: P• D. FLow = 33o G•P,o. PL=0 CAt 1*60 .RATE 1 04* 2 MINI 02 LESS ._� .•. � :._.fir.+w �PvV OF Mq� ' �i�,r1ARD �s PcTER SULLIWAN..._ ~s -(WTER 4 N. , tee a404:3 0 29733 _ TEsr'fra� 457�, sit �y '.. TH* 1 EL. 39.7 F'G• � 39. o L0 AM I r Sv4,So/L /OOO :•..� /y9 DED /coo 5 BOX /Nl� GAL, 3, 4' �� � ` l to 6.5` 37, l sE.�rf'G 37 v. p,T .o TAN%G SA,v� •• # 7oJ ' 3617 36.9ST- c',E,2T/F/E'O PGor� ,ot�4�✓ . cL.277 PRoFt LG zs7 No SCALC PZ4A) O oC .6-4106 ,cv IZ; VD :WqIE_/Z_ F.v p.. PILo/�o S�L� GE,eri,C•Y Tf/,4T'T//. F 7�w�CU�tG S.y4W.v Z��ZoTIY: 2. 139K 1Z/ .�/E.�Eov GOM�GY.S !,v/TX/Th�.E S/O�'�,/�t%E B•dXT�.2€�t/l�E /NG. AtiO.SE'TI�/JGf� .eE4V/�E�I�Nr.S o-oa 7M4 ,C�EGisr�,er ,Gcicio•Sli,2�Eyo,�S Tox�.v of SA2.Av57;9gLe Am.27 /,S iVOT G�ST�.2Y/LLc �tf,�.� LOC.�TE,O L1//Thy/y T.Y.E �LaoOPG.Q/�V. T//!s dll4,d'.v /s ,s/oT- a.4sE0 aYv.4,v/.-1$71e- -r/.sl,E�Yr•.Sv,2�/Ey.4iv0 TfiE S�lyiv f�E•e��N,5,4,/l�UG��pT!�E USEp Ta E.s7.�L/sy Low-,G/NE,S No. �V + Fee T �� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes :M RppliLation for -Mispo8al 6pstrm Construction VennIt Application for a Permit to Construct Repair Upgrade Abandon Complete System ��dual Components s Location Address or Lot No./y s+ Owner's Name,Address,and Tel.No. 06 rp+1, 6,�f� v( IBC YEA- .�2f � Ie6 �sPe�d,�//E'� OF 8G223 Assessors Map/Parcel S (�t] Installer's Name,Address,and Tel.No.l7 iIsclok O �e T Designer's ame,Address,and Tel.No. of O 4C L 1'J t, Type of Building: Dwelling No.of Bedrooms A Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 30 gpd Plan Date m;* GK t Number of sheets Revision Date Title ,p Size of Septic Tank ZQ OD Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) \s J i S l�! f,�- "AA a A Date last inspected: 2 '" 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 th system in operation until a Certificate of Compliance has been issued by this Board of Health. / Date Application Approved by Vw Date /I _ r' Application Disapproved Disapproved b Date for the following reasons Permit No. Lo i-3 4`, Date Issued ( / ---------------------------------------------------- --- - No. y�.J �G� i Fee �, / THEntered in computer: COMMONWEALTH OF MASSACHUSETTS Yes 1 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Npfication fouDisposal *pstent Construction Permit . . i Application for a Permit to Construct Repair(� Upgrade Abandon Complete System /ndividual Component,tsh Location Address or Lot No. Owner's Name,Address,and Tel.No.' D6 t01.1, Assessor's Map/Parcele 4411 0 2 t Installer's Name,Address,and Tel.No. t),&Aon 10 Sew-ems Designer's Name,Address,and Tel.No. �. Ct,„d p0G��. - ,Vk A4 0?6 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(,Nr Other Type of Building 12C,S i PK-F�`µ No.of Persons Showers( ) Cafeteria ) j Other Fixtures ~ Design Flow(min.required) 6 I gpd Design flow provided 3.3 D gpd t ! Plan Date //y-e 6✓1 i'l- ,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) S'f (, "�'(.�^t�'�n °�( Q v� : /�yr q , ' 'r Date last inspected: A/ -Agreement:' i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place/the.system in operation until a Certificate of Compliance has been issued by this Board of Health. +� Signe Date Application Approved by (n,.. r>or Date Application Disapproved b G� Date , for the following reasons Permit No. -d 1' i 3 Sl_ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS 4c-,A Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( "}� Upgraded( ) Abandoned( )by r at a j1.. rrJ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 01 dated 1{ l l i Installer Designer #bedrooms it, Approved designn flow l gpd The issuance o th s�er' shall not be construed as a guarantee that the system w' func[iJd as`des' ed. Date ( Inspector ✓ �, 1�( ----------.-----D--------------------------------------------------- ---------------------------------- ------------------- No. I� 3 0 Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit. Permission is hereby granted to Construct( ) Repair(/))) Upgrade,( ) Abandon( ) System located at r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Con`t ruction must be completed within three years of the date of this permit r,' Date /tr Approved by AsBuilt Page 1 of 1 ti LOCATION ..SEWAGE PERMIT NO. VILLAGE �gINST,ALLER'S NAME , i ADDRESS BUILDER OR OWNER b rel, t" DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �,H t o d Kok. http://issgl2/intranet/propdata/prebuilt.aspx?mappar=l 18100&seq=1 11/2/2015 I //b - 1UU Commonwealth of Massachusetts Title 5 Official Inspection Form a Di _ OA Subsurface Sewage Disposal System Form Not for Voluntary Assessments 142 Pond Street Property Address -- -- John Ryley ___ _ Owner Owner's Name --- information is required for'every Osterville ✓ MA 02655 _ May 14, 2019 _ ' - page. Cityrrown _ _—_ _ _ _ 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 A. Inspector Information C � --- filling out forms p � 3 on the computer, use only the tab Patrick T. Sullivan _ key to move your Name of Inspector — cursor-do not Ready Rooter Excavating _ use the return Company Name -- ------ key. PO Box 89 Company Address -- Forestdale _ MA 02644_ _ Cityfrown — — State Zip Code return ` ` 508-509-0802 S112843 Telephone Number. License Number B. Certification � ------- ---- -^----- certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails May_15 2019 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. "imso noc•rev 712612018 Title 5 Official Inspection Bonn SUhsUrfacF sewage Dlsporal System•Page 1 of 18 e: t r . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond Street Property Address John RyleY._- — - -----------.....__. ._.. __...- Owner Owner's Name on isrequired for every Cisteryille MA 02655 M_._a._y_.1.._4._,,2....0..1.-9--..._.. page. City(rown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that,the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): -,sp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 J 4 .� Commonwealth of Massachusetts p Title 5 Official Inspection Form — I- Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 142 Pond Street Property Address John_R ly ey Owner Owner's Name information is Osterville MA 02655 May 14, 2019 _ required for every _- — — — Y page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.):. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to`a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y -❑ N ❑ ND (Explain below): ❑ obstruction is removed' ❑ Y ❑, N ❑ ND (Explain below): . j ❑ distribution box is le-ieled or replaced ❑ Y ❑ N ❑ ND (Explain below): i" j ❑ 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: El 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: l5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts -�10 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .Y 142 Pond Street Property Address John Ryley Owner Owner's Name information is Osterville MA _02655 May 14, 2019 required for every --_ — page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) T ❑ Cesspool or privy is within 50 feet of a surface water r ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Hee (h hand Public Water Supplier, if any) determines that the system is functioni. n a manner that protects the public health, safety and environment: j- ❑ 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 aseptic tank,and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic t�hk 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 01 15msp dor.•rev 712612018 1 We 5 Official Inspection berm 3tibsurfare Sewage Disposal System•I>age 4 of IS Commonwealth of Massachusetts - Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w�• / 142 Pond Street / Property Address John'Ryley Owner Owner's Name information is Osterville MA 02655 May 14, 2019 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/.day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped- -_ . ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑, ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either.•"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system i%within 400 feet of a surface drinking water supply i ❑ ❑ 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 a Are '- IWPA) or a mapped Zone II of a public water supply well i:nnsU duc•iev 7/26/2018 1itle 5 oHicual Inspection i orm Subsurface Sewage Disposal System•r'aye.c,of i S Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �\ 142 Pond Street .. Property Address John Ryley Owner Owner's Name information is required for every Osterville MA 02655 May 14, 2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the'SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i S,nsp(for.•r,w i12612018 Ii110 5 Official Inspection roan Subsurface Sewage lhsposal System•Pagr.Fi of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form —_ Subsurface Sewage Disposal System Form - Not for Voluntary 9 P Y Y Assessments 4 �. 142 Pond Street Property Address John Ryley Owner Owner's Name - information is Osterville MA 02655 May 14 2019 required for every Y ,_ . _....... . page. CityRown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2.. Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 392 GPD Description: 6 x 6' leach pit w/2' stone. . .Number of current residents: 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2017= 175 GPD* 9 ( Y 9 (gp )) 2018= 249 GPD* Detail: *.Irrigation is on meter. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date (5insp.doc•rev 7126/2018 Title 5 Offinial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts = ; Title 5 Official Inspection Form n1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond Street Property Address John RYley __._. .. - - Owner _ .......__ _ Owner's Name information is Osterville MA 02655 May 14, 2019 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 2. Commercial/Industrial Flow Conditions: N.. 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'.f Date Other (describe below): 3. Pumping Records: Source of information: Owners records: Pumped Fall 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp cloc•rev 711612018 1 tlh:5 Official Inspection I-erm Subsurface Sewage Disposal System•Page 8 of III III Commonwealth of Massachusetts - Title 5 Official Inspection Form -== � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �r F 142 Pond Street Property Address John Ryley Owner _ . . Owner's Name information is required for every Osterville MA 02655 May 14, 2019 page. City/Town State lip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System installed Oct. 17, 1985. Certificate of Compliance on file at Health Dept. D-box is newer. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet . Comments (on condition of joints, venting, evidence of leakage, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond Street Property Address John Ryley Owner Owner's Name information is required for every Osterville MA 02655 May 14, 2019 -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: -- -- g - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' x 4.5' x 5' 1000_gallons 6" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 10" at inlet, 2" at outlet _ 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 -12" - ----- How were dimensions determined? Dip tube and 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.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Recommend maintenance umpiing within 3 months due to hem solids. 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 i,� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 142_Pond Street _ ~� Property Address John R leY--- ------ - Owner Owner's Name information is ill t Oserve MA 02655 May 14, 2019 required for every ---- - — — —y — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ; ❑ concrete ❑ metal �6 fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i Scum thickness ` - -- — — --- Distance from top of scum top of outlet tee or baffle Distance from bottom of soGm to bottom of outlet tee or baffle — - - — -- Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan).- Depth below grade: - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)-. j Dimensions: i Capacity: % gallons Design Flow: ' gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts _^ Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond Street Property Address John Ryley Owner Owner's Name information is Osterville MA _02655 Ma 1 required for every --.--_.__-_--_ _-- _— —�_4, 2019 -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: Yes ❑ No Alarm level: • Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition'of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 - Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. Light solids carryover. No high water staining over outlet invert. D-box has beed replace. No permit found. H-20 DB-3. 2' below grade. Riser brings cover 10" below grade. Debris from old d-box in soil over new d-box. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 142 Pond Street Property Address John Ryles -- Owner Owner's Name information is Osterville MA _02655 May 14, 2019 required for every -- ----- - -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: /V ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i i If pumps.or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 1-6' x6' w/ 2' ® leaching pits number: stone. ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 .ti Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 142 Pond Street Property Address John R_ ly ey —_ Owner Owner's Name information is Cisterville MA 02655 , 2019 required for every _- 14 --.-. page. CityrTown State Zip Code Date of Inspection D. System, Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit has 6" of liquid at time of inspection. High water staining 18" up from base, 5' below top of pit. Inlet line enters short riser above pit. Camera used to locate and inspect pit. No sign of past 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.): l i ?' t5insp.doc•rev.7/2612018 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 , 142 Pond Street Property Address John Ryley Owner Owner's Name information is Osterville . MA _02655 May 14 2019 required for every Y ,—_ — 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 draulic failure, level of ponding, condition of vegetation, etc.)-. j t5insp.doc•rev.7/26/2018 Title 5 Official Inspection:Form:Subsurface Sewage Disposal System-Page 15 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments {K' 142 Pond Street Property Address John Ryley _ Owner Owner's Name information is required for every Osterville MA 02655_ May 14, 2019 -------....-__-....-----..-..-----------------------------...- ------ _..---- ---- 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 V_ > S- r, S-( J -5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 '• �� Commonwealth of Massachusetts , s Title 5 Official Inspection Form _ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - ` 142 Pond Street y t Property Address John Owner Owner's Name information is Osterville _ _ MA 02655 _ May 14, 2019 required for every _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water o ❑ Check cellar ❑ Shallow'wells Estimated depth to high ground water: >5 - - feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record 1985 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health _explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: maps.m assg is.state.ma.us/oliver.ph p You must describe how you established the high ground water elevation: Slope to pond drops 35+ Base of leach pit 9' below grade. Accessed local ground water contours and topo mapping No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 142 Pond Street Property Address John Ryley Owner Owners Name information is Osterville MA 02655 May 2019 required for every ------- MA------ --------- ---y 14--'------------- -- page. Cltyrrown 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 4 J t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 or 18 e i m /!p it A. + 3 o BAX�ER Na 240vQ 10 - �G�BTfcgyG� �Cxl� I II V . C'E,eTi,�/Ep ocv7' / C�".2T/.may T.U/7T TNT FovA)D47-10AJ LaC,4T S�/OWiLr h�E/2E0.(/Cols-J.�L YS Gl//Thy SCA Z �- f i� L7.4 T� r,,4/, s X0.5:4/iG/Z-- A.,V,r- SE TBA Cl- 2EQU/.2E�ENyS o,c- T!/z= �,4 T.E: XT�,2s/VyE Tf//S P,4,41//S .It/a7- B.QSEO Apt/ ,26G/STE.2EO L.�/p ,�U,eY�ypr�I I � • I � D O , OFFICIAL USE Certified Mail Fee a $ , NISI Extra Services&Fees(cfreck box,add fee as approp�aie)o 9 ❑Return Receipt(hardcopy) $ 0 ❑Retum Receipt(electronic) $� y Postma Q Certified Mail Restricted Delivery $ r /D�Hef9 E-3 ❑Adult Signature Required $ ❑Adult Signature Restricted Delivery$ t7 Postage Ln Total Postage and Fee �`S _$ Dorothy Baker 4830 Kennett Pike#3106 Greenville, DE 19807 Certified Mall service provides thle following benefits: ■A receipt(this portion of the Certified Mail 1&7-1`jhj for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attemp `retan receipt for no additional fee,present this- delivery. USPS®-postmarked Certified Mail receipt to the, ■A record of delivery(including the recipients retail associate. signature)that is retained by the Postal Service'" Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent —, Important Reminders. Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not , First-Class Wife,First-Class Package Service®, available at retail). or Priority Maile service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age International mail. and provides delivery to the addressee specified- ■Insurance coverage Is notavailable for purchase by name,or to the addressee's authorized agent.. with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatirally included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on, ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion, of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply , You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.r 1 I electronic version.For a hardcopy return receipt, r, complete PS Form 3811,Domestic Return i Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this recelpt for your records. Ps Four,3800,April 2o15(Reverse)PSN 7530-02-000.9047 COMPLETE • I COMPLETE THIS SECTION ON DELIVERY E Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. 0 Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Rec ' e (Printed Name C. D to of Delivery ■ Attach this card to the back of the mailpiece, or on th$"nt if space permits. manl /•o D. Is d �delivery address different from item 1? Yes;. ,1. Article Addressed to: ,• If YES,enter delivery address below: ❑No '"r orothy Baker 4830zKennett Pike-#3106: Greenville, DE 19807 3. Service Type a ❑Certified Mail® ❑Priority Mail Express' � ❑Registered. ❑Return Receipt for Merchandise E3 Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7�1552O 0O0.� 1971 7040 ,I (transfer from service label) lYs` PS Form 3811,July 2013 Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4®in this box• Z3�_ . .. . ...... . r Town of Barnstable Barnstable OFSNE 1�,_ Regulatory. Services Department • snxxsr�ece, • � D MAM Public Health Division zoos 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0000 1971 7040 November 10, 2015 Dorothy Baker 4830 Kennett Pike#3106 Greenville, DE.19807 The septic system located 142 Pond Street, Osterville,MA was last inspected on Oct 27,201.5 by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The Health Division has determined that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310. CMR 15.00) due to the following: , • Rotted distribution-box needs to be replaced. • Septic tank is leaking. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH i_ Q5 IS s cKean, R.S. CHO Agent of the Board of Health r Q:\Letters septic Inspection Failure or Further Evl\142 Pond St Ost Nov2015 � Parcel Detail Page 1 of 3 rIT MIN F c } { g ....• " �� 6a /f,c&a vat Logged In As: Parcel Detail Monday, November 9 2015 Parcel Lookup Parcel Info _ 118-100 Developer Parcel ID Lot Location J142 POND STREET Pri Frontage�121 Sec Sec Road Frontage Village;OSTERVILLE Fire District C-O-MM ' Town sewer exists at this address I I`i0 I Road Index,129 N I Asbuilt Septic Scan: Interactive ' 118100_1 Map - Ial.-Il - Owner Info Owner BAKER, DOROTHY R TR Co-owner 4DOROTHY R BAKER TRUST Streetl „4830 KENNETT PIKE#3106 Street2 City;GREY ENVILLE i State DE zip 19807 Country - Land Info Acres[0.3_8 �I Use Single Fam MDL-01 Zoning,Rr C. � Y� � Nghbd 10111 Topography I Road I Utilities Location I - Construction Info Building 1 of 1 Year 1985 Roof Gable/Hip ' I Ext Wood Shingle Built Struct Wall Living 1502 � Roof Asph/F GIs/Cmp O AC Area Cover Type None Style Cape Cod Int Drywall Bed B rooms �'m Wall Rooms Model(Residential Int Carpet ( Batn 2Full-0 Half ( " ' Floor Rooms BA Grade AVera e _ Heat Total ° .g TQS _... Type ;Hot Water Rooms 5 Rooms �� Heat Found Stories 1 1/2 Stori`"" """"es Fuel [oil �� ation 1pou� red Conc. � o �. Gross 2770 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=7133 11/9/201 S ` Town of Barnstable 1AIiNJrAHLA A �9 ,�� Regulatory Services .Department rFD MA't� Public Health Division . 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6,2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code_ §360-9.1) OTHER 204J d—bux 0iV1J 40,11( ;s Ie1r, k,A Repair deadline: VeA — t Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 01/ 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond st . Property Address Dorothy Baker Owner Owner's Name ----- ---- IEI information is r_•r Osteryille ✓ Ma 02655 10/27/15 required for every page. City/Town State Zip Code Date of Inspection I` i"ti al Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuon_o use the return Name of Inspector key. - DiBuono Sewer and Drain Company Name ---- -- 8 Johns path Company Address Prw� S Yarmouth ____ MA _ 02664 City/Town State Zip Code 508-364-9587 _ S113522 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 10/29/15 I pector's Signature Date _ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. /fyVS15ins•3/13 Title 5 official Inspection Form:Subsurface Sewage DispoIYP�ge t of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \a, 142 Pond st Property Address --------- Dorothy Baker Owner Owner's Name information is Osterville _ Ma 02_655 ,10/27/15_required for 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrete Distribution box. Distribution box is rotted and root bound. The tank is leaking at the middle seem between the top and bottom halve. The ip t is dry and has seen little use. Seasonal home. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 2 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - _ 9 p Y Y titer, 142 Pond st _ — Property Address Dorothy Baker _ Owner Owner's Name information is required for every Osterville Ma 02655 10/27/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Needs a new DBox. And a tank seal. ❑ 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 15ins•3113 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts �U - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 142 Pond st _'- Property Address Dorothy Baker _ Owner ---__--— ----__-- --•-------—----------— ------------------------- Owner's Name T information is Osterville Ma 02655 10/27/15 required for every _ _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5i-is•3113 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 \a- rT 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is required for every Osterville Ma 02655 10/27/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No 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 El ® 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•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 5 of 17 zP i•`s. Commonwealth of Massachusetts F Title 5 Official Inspection Form �,— Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is Cisterville _Ma 02655 _ 10/27/15 requi-ed 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? ® ❑ 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): 2 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 t51ns•3/13 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form J?,I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is Osterville Ma 02655 10/27/15 required for every «_ _. page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. Distribution box is rotted and root bound. The tank is leaking at the middle seem between the top and bottom halve. The_pit is dry and has seen little use. Seasonal home. Number of current residents: 2 gym, Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) P ) Laundry system inspected? ® Yes ❑ No Seasonaluse? i ® Yes ❑ No Water meter readings, if available last 2 ears usage d 73.5 GPD 9 ( Y 9 (gP ))� Detail: .Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: =— -- Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): -- Grease trap present?, ❑ Yes; ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - -- t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond st Property Address Dorothy lBaker Owner Owner's Name -- -_--------- --- - __- ----- information is Osterville Ma 02655 10/27/15 _ required for every _ — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: --- ---- ------- — ----- Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe). t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 0 . Commonwealth of Massachusetts � M Title 5 Official Inspection Fora - Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is Osterville Ma . 02655 10/27/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 18 — — feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): -- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. _ Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) _1000 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑. Yes ❑ No Dimensions: `t --- — Sludge depth: — t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - -= I _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e- 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is Osteryille Ma 02655 10/27/15 required for every _- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 — _-- Scum thickness 3 -- ----- Distance from top of scum to top of outlet tee or baffle 42 — —_ -- Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick _ — How were dimensions determined? 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.): Evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f , . Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is required for every Cisterville Ma 02655 10/27/15 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place Leaking at seem Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: -- Capacity: ---- -- gallons Design Flow: gallons per day Alarm present: ❑ Yes '❑ No Alarm level: — -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form 8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond st Property Address — Dorothy Baker _ Owner Owner's Name information is Cisterville Ma 02655 10/27/15 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Rotted and decayed 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.): Distribution Box is rotted and root bound Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u� W Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments \a � 142 Pond st Property Address Dorothy Baker Owner Owner's Name — � _�— — - -- — information is required for every Cisterville Ma 02655 .. 10/27/15 — _— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. 1 ® leaching pits number: - ❑�_ leaching chambers number: " ❑V..: 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.): No signs of carryover and no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - -- Depth -top of liquid to inlet invert - r Depth of solids layer Depth of scum layer - — Dimensions of cesspool Materials of construction - Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 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 ®, 142 Pond st Property Address Dorothy Baker Owner Owner's Name --- regjir atifo is Osteryille Ma 02655 10/27/15 _required for every _ pace. City/Town 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.): No signs of pondincgor hydraulic failure. 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.): t°•ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 LOCATION SEWAGE PERMIT N0. VILLAGE - �gINST.ALLER'S NAME , ADDRESS M I U I L D E R OR OWNER r DATE PERMIT ISSUED --� DATE COMPLIANCE ISSUED - Commonwealth of Massachusetts (7) P ( "Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 142 Pond st Property Address Dorothy Baker Owner Owner's Name information is _Osteryille Ma 02655 10/27/15 required for every — _— —__ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area.below ® drawing attached separately 15ins•3/13 Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 142 Pond st Property Address - Dorothy Baker Owner Owner's Name ----- --- — ------------------- ----- information is Osterville Ma' 02655 10/27/15 required for every _ _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ ftfeet — ---- 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: Near by pond at a much lower elevation Before filing this Inspection Report,-please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form - ,=l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' e- J 142 Pond st Property Address Dorothy Baker _ Owner Owner's Name —� information is Osterville Ma 02655 10/27/15 required for 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 t t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 17 of 17