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Home My WebLink About0127 REBECCA LANE - Health 127 Rebecca Lane Osterville P A = 146 056 1 Commonwealth of Massachusetts u ro Title 5 OfficinalInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r � 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is STERVILLE MA 02655 3/8/2021 required for every CI , page. City/Town State Zip Code Date of Inspection Inspection resultsmust be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, h Christo use only the tab per Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return Company Name key. 350 Main Company „y Company Address W Yarmouth MA 02673 Cityrrown State Zip Code > 508-775-2825 •SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my.-training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. El Fails �.- 3/11/2021 Inspector's Signatu a Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name Information is required for every OSTERVILLE MA 02655 3/8/2021 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: SYSTEM IS IN WORKING CONDITION .,r 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): 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is OSTERVILLE required for every MA 02655 3/8/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ ' distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a.year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1.).(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form`- Not for Voluntary Assessments 127 REBECCA LANE V Property Address CLAUDIA FLORES Owner Owner's Name Information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well; ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2e12018 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 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due.to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high groundwater 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 31.0 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 J ❑ ❑ 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 l5insp.doc-rev.7126/2018 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 ,� % 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 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 the1acility 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)] t Sinsp.doc-rev.7/2612018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forml- Not for Voluntary Assessments 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 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 Description: Number of current residents: 3 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 '20- 153 GPD 9 ( Y 9 (9pd)) '19- 153 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date M t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts' i Title 5 Official Inspection Form F1n` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V, 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions:- Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.712 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of.Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name Information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code _ Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ED No 5. Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water-supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l% 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655' 3/8/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 14"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: 2" Distance from top of sludge to bottom of outlet tee or baffle 'Scum thickness 211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. FILTER IN PLACE IN OUTLET OF SEPTIC TANK. TANK AT NORMAL OPERATING LEVEL. COVERS 14" BELOW GRADE 15insp.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 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 page. Cityfrown 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: . Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other' (explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-'Page 11 of 18 i Commonwealth of Massachusetts . Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is f required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) r 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 EVEN 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 LEVEL AND WATERTIGHT t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on_site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments note condition'of um chamber, condition of um s and a urtenances etc.): ( P .p � pumps pp � ) I * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4- INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ' ❑ innovative/alternative system I Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a v 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 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.): 4-INFILTRATORS WITH STONE. 13'X40'X9" FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of.18 Commonwealth of Massachusetts OF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name information is required for every OSTERVILLE MA 02655 3/8/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r F i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 i Commonwealth of Massachusetts Q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 REBECC A LANE Property Address CLAUDIA FLORES _ Owner Owner's Name Informationis required for every OSTERVILLE MA 02655 3/8/2021 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 t � q-ql 38 ,y f ►3 1�1 ' I 0 , i 15insp.doc•rev.V2612018 Title 5 Official Inspection Form:Subsurface Selvage DiWosal System•Page 16 of 18 L i Commonwealth of Massachusetts Title 5 Official Inspection form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name requiratiforon e OSTERVILLE MA 02655 3/8/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +12' feet Please-indicate all methods used to determine the high ground water elevation: j ❑ 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: HAND AUGER PERFORMED ONSITE AT TIME OF INSPECTION TO 12'2" ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 6' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 REBECCA LANE Property Address CLAUDIA FLORES Owner Owner's Name Information is required for every OSTERVILLE MA 02655 3/8/2021 page. CitylTown 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 f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 18 of 18 I Commonwealth of Massachusetts _. --- Title 5 official Inspection Form' - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre ! 5 Owner Owners Name information is CO required for every Osterville Ma 02655 10/3/2018 : page. Cityrrown State Zip Code Date of Inspection CAI j Inspection results must be submitted on this form. Inspection forms may not be altered in-any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Sean M. Jones key to move your Name of Inspector �+ cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co � Company Address Centerville _ Ma 02632 City/Town State Zip Code 508-658-3456, 774-248-4850 '` SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); I 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 r - 3. ❑ Needs Further Evaluation by the Local Approving Authority,* 4. ❑ Fails 10/3/2018 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 antl 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. i5insp.doc rev.7262018 Tula 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 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page, Cityrrown State Zip Code Date of Inspection C. Inspection Summary 4 Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. - 1) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 127 Rebecca Ln Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 4 3050 Infiltrators. The system was found to be in proper working condition at the time of inspection. 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 ❑ NO (Explain below): t5;nsp.doc•rev.72WO18 Title 5 Official InspMon Form;Subsurface Sewage Disposal System•Pape 2 of 18 I Commonwealth of Massachusetts ' A---, Title 5 official Inspecti6n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is Osterville _ - Ma 02655 10/3/2018 required for every ' page. CitylTown state Zip Code Date of Inspection C. Inspection summary (cons.) 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 pipes) 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 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.doo•rev,7rAr418 Title 5 Official Inspedion form,Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 official Onspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityfrown 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 SacKup 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 t!incp,doc•rev.7t25=18 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 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name informrequired is Osterville- Ma 02655 10/3/2018 required for every page. Cityrrown 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 of 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 16,000 gpd. r For large systems, you must indicate either."yes"or"no"to each of the following, in addition to the questions in Section C.4._ 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 Mnsp.doc•rev,7126/2016 Title 5 Official Inspection Forth: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 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is'considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No - ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7126018 Tilts 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owners Name information is Osterville Ma 02655 10/3/2018 required for every 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 6Ld 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? T1 Yes ® No Last date of occupancy: current Date t51nsp.doe•rev.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pagel of 18 Commonwealth of Massachusetts -_ Title 5 official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is Osterville Ma 02655 10/3/2018 required for every page, City/Town State Zip Code Date of Inspectlon 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15 nsp.doc-rev 726/2018 Tide 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts , - - Title 5 official Inspection Form ` Subsurface Sewage Disposal System Form Not for Voluntary Assessments , 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name required on is Osterville Ma 02655 10/3/2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 4. Type of System: Septic tank, distribution box, soil absorption system t ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of,the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system repaired 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate,on site plan): Depth below grade: 2 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.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc•rev,V2612018 Title 5 Official tnspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection i`ori Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/201 S page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' 6. Septic Tank(locate on site plan): Depth below grade: 1.5 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: 6" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 11" opened covers and took How were dimensions determined? 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 for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t$inap.doc•rev,7/2t112018 Title S 0fricial Inspection Form.Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts F { Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owners Name information is Osterville '" Ma 02655 1013I2018 required for every -_ page. Cityrrown State Zip Code Date of Inspection _ D. System Information (cont) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: • . ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene [] other(explain): 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: - s - I I -Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 11 of 18 Commonwealth of Massachusetts - 1 : = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner owner's Name information is required for every Osterville Ma 02655 10/3/2018 , page. City(Town State Zip Code Date of Inspection D. System Information (cunt.) 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5lnsp.doc•rev.7126/2018 Title 5 official inspection Form Subsurface Sewage Disposal System•Page 12 of 10 c� Commonwealth of Massachusetts - Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owners Name information is Osterville Ma 02655 10/3/2018 required for every ' page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) , 10. Pump Chamber(locate on site plan): Pumps in working order: F ❑ 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: ® leaching chambers number: 4 3050 Infiltrators ❑ Teaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number ❑ innovative/altemative system Type/name of technology: l5inep.doc•rev.MM2018 Title 5 Official Inspection Form;Suosurfew Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts - - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary-Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,-etc.): Leaching facility was video inspected from d-box and was found dry with no signs of past hydraulic overloading. 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:insp.doc•rev.71=018 Us 5 Official Inspection Form,Suosurface Sewage olsposal System-Page 14 of 18 Commonwealth of{Massachusetts y =- Title 5 official Ifispection Foam! Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane u Property Address Karen Sparre Owner Owner's Name information is Osterville Ma 02655 1013/2018 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): • ' Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doe•rev.7/26/2018 title 5 official Inspection Form Subsurface Sewage Disposal System•Pager is or 1a Commonwealth of Massachusetts =� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments , 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 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 fut -. I U At ` C�---�, Z 03 f 7k f�3 N(p Y 6 � t6inap.doo•ray,712012010 Tills 5 Otkiel Impaction Form.subaurface sewayu Oispusel system•Page io of i a r Commonwealth of Massachusetts f _- Title 5 Officiel Inspection' Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • L 127 Rebecca Lane Property Address Karen Sparre Owner Owners Name information Is required for every Osterville Ma 02655 10/3/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: { ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 12'+ Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on-record lUchecked; date of design plan reviewed: .6-18-2003 . 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page.. t5insp doe•rev-71roala Toile 5 Official inspection Form-Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official 8nspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,,..� 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name Information is required for every Osterville Ma 02655 10/3/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist, , Complete all applicable sections of this form inclusive of: A. inspector information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15inep.doe•rev.7l26/2018 Tick 5 official Inspection Form;Subsurtece Sewage Disposal System•Page 18 of 18 TOWN OF BAMSTABLE LOCATION 117 ArA!ZeC-C_ Lam. SEWAGE # 1003-,12g�/ VILLAGE 057;02U1LL E ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. A1/3Z,-Zj' //6X4�7,< _ SEPTIC TANK CAPACITY /boo GAL LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER- /Y04, 7i9-V � PERMITDATE: 613010-3 COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili�) Feet Furnished by �� O �� , ��. tj{ � � I i tO �~ � � _ -� v 00 ;LW 3 46 4 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in comp - Yes Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETT ZIppYicatfon for Migogal *potem Con0truction Vermtt Application for a Permit to Construct("V paair(grade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. j Z 71,7etj @C fit/' Owner's Name,Address and Tel.No. Assessor's Map/Parcel /-9te Q-s(P Q S`v-,v1 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size �Acic'-9 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons `Z. Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�' Q ^�c<o gallons per day. Calculated daily flow i7 r gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /®GG Type of S.A.S. Description of Soil /45�' Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued by this Board of Health. gne `j`_.Z Date Application Approve Date Application Disapprored for the following reasons w m ermit.No Date Issued le r �—————————————— ---- - 00 msjt 114 4- No.�'W 3 r. r`, Fee' V ��-7� ' A /. Entered in computer: //'� !�'C JI•V THE COMMONWEALTH OF MASSACHUSETTS , 4" Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS "Application for Miopooar *potem Construction Permit �P& �� 3 Application for a Permit to Construct(`pt)°lZepair(grade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 17 �� C C� G�/ Owner's Name,Address and Teel.No. ` Assessor's Map/Parcel iy1, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms. =` Lot Size sq.ft. J Garbage Grinder( ) Other Type of Building - No.of Persons Z Showers( ) Cafeteria( ) Other Fixtures t i i .. ; J✓ .r �. Design Flow 3 3 0 6o gallons per day. Calculated daily flow _P? gallons. d Plan Date Number of sheets Revision Date Title - 1 Size of Septic Tank /OGG Type of S.A.S. Description of Soil ',0?1 t l Nature of Repairs or Alterations(Answer when applicable)oe 4 'V e Date last inspected: 3 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 Certifi- cate of Compliance has been issued by this Board of Health. Date " Application Approve Date �� 3 Application Disapproj ed for the following reasons as • Permit No. G�C3 3 " c�-� Date Issued It U --_ ; -------------------—----------------- tn "' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded( ) Abandoned( ) y at 17-9 `f c"k _ - has been constructed in ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 003-2W dated to/2 4, D 3 Installer Designer The issuance oft s p frn shall not be construed as a guarantee that the system w 44 ncti Date 3 Inspector nLckj No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigogar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( 9 j Upgrade( )Abandon( ) System located at 1 1-7 (2�be-c e-9 LpN 2 �:)_- e ,,((Q and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the dat Qthise t.Date: 4�3 Approved TOWN OF BARNSTABLE LOCATION 17 SEWAGE # .2003 - � � �e C�- ASSESSOR'S MAP &LOT !L sG' VILLAGE OV201f(� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I W 62 4I0-*-w LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 30/ COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells.exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facili ) Furnished by /y 13 t Yt,1 O �- (NO bol C\j cc� ��15 Mq HYAN N IS MARINA x � cgPE Co� 1 Willow Street• Hyannis, Massachusetts 02601 Tel: (508) 790-4000 Fax: (508) 775-0851 Email: info@hyannismarina.com Ap �. 9 Sea.Craft FORMULA Commonwealth of Massachusetts 0% Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is Osterville ✓ Ma 02655 10/3/2018 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Imngoutforms A. Inspector Information S/ h /34/� filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return key. Company Name Co pang A Lane �y Company Address Centerville Ma 02632 CityrFown r State Zip Code ran 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 16.340 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 10/3/2018 Inspectors 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 acid copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 y Commonwealth of Massachusetts Title 5 Official Inspection Form <t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owners Name information is required for every Osterville Ma 02655 10/3/2018 page. City[Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: , The dwelling located at 127 Rebecca Ln Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 4 3050 Infiltrators. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 {� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner . Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityfrown State Zip Code Date of Inspection i C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is-removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is Osterville Ma 02655 10/3/2018 required for every page. City/Town State Zip Code Date of Inspection C.. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No. ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre . Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No i • I ❑ ® Static liquid level in the distribution box above outlet_ invert due to an overloaded or clogged SAS or cesspool ❑ El than 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 is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7I26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 hi Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I� 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r� c Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owners Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityrrown 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: 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.7/262018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information's required for every Osterville Ma 02655 10/3/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system repaired 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: p pp y feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages.Vented through roof t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osteryille Ma 02655 10/3/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 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 6,- Sludge depth: Distance from top of sludge to bottom'of outlet tee or baffle ' 3' 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" 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 for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.7l2612018 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lug Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 01 8 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 l Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. . Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): • F *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 01. 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 was level and.in good condition with no rot.Water-level waseven with outlet invert with no signs of past backup. t5insp.doc•rev.7/26r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 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: ® leaching chambers number: 4 3050 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018- page. Cityrrown 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.): Leaching facility was video inspected from d-box and was found dry with no signs of past hydraulic overloading. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts r' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane' Property Address. Karen Sparre Owner Owner's Name information is required for every Osterville ' Ma 02655 10/3/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) -: 13. Privy(locate on site plan): Materials of construction: Dimensions f Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • C t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is required for every Osterville Ma 02655 10/3/2018 page. CitylTown 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 � iU A( Z' 6 13 ao Al 3/ f33 31i"� y y3'(v, t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 127 Rebecca Lane r Property Address Karen Sparre Owner Owner's Name information is Osterville Ma 02655 10/3/2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑' Check Slope ❑ Surface water µ ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6-18-2003 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Rebecca Lane Property Address Karen Sparre Owner Owner's Name information is Osterville Ma 02655 10/3/2018 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B:Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7r2612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Home Iri§pectiori : Title V Inspection f Water&Radon CONLMONWEALTH OF MASSACHUSETTS . 7 - XECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' Y1�`J 2 TMENT OF ENVIRONMENTAL PROTECTION 0 TER STREET.BOSTON MA 02108 (617)292-5500 �� ► Bob Lalime Rf�r�vED Licensed&Insured / W1?.LLAX F. MAY SPECT ALL TRU SY�� Governor 1 ran o Cn j l01'Q OF 1 J J 0 (508)539-8047 DAVD B.STRUM ARGEO PAUL C.I!, H.rAI�ARk'r;n;r Co, -•;«;�� Lt.Governor �k�; e. SL'BSL'RFACQ_ WAGE DISPOSAL SYSMNI RiSPECTION FORINI PART A // CERTIFICATION Property Address: 127 of zvcc ,Ip Lam P Address of Owner: SlJpoP Date of Inspection: c;.r (If different) Fume of Inspector: Ac b 1!y I am a DEP apmved system inspector p suant to Section 15.340 of Title 5(310 C)`IR 15.000) Company Name: c/ mailin;Address: Telephone Number: =,p, S,a o! eC7 S�7 , CERTIFICATION STATEtiiENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes • Condi:iorally Passes _ Needs Fu r Evaluation By the Local Approving Authority _ Fails J Inspector's Signature: /, Q Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 inspec:or and the system owner shall submit the report to the appropriate regional office of the Depammertt of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. LtiSPECT70N SLNDLkRY: Check A,® C, or D: AJ :1'.;t E-M PASSYS: I have not found any information which indicates that the system violates any of the failure criteria as defined it..310 C`LR 15.303. Any failure criteria not evaluated are indicated below. CO�L`iF`?S: BI SYSTE:1,1 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. Indicate yes. Ito, or not determined (Y.N.or YD). Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection:or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 V.i P—ted on Recycled Vsper c , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: Owner: Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) _✓ Sewage backua or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced �7 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 4', _ 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 ENVIRONMENT: l� 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. i/ The system has a septic tank and soil ?bsorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a —11 w•atpr hart ?red volatile organic 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes"or "No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _y 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 ]eve! in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. y Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. N 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 Soil Absorption System. cesspool or privy is below the high groundwater elevation. /6 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. • 41 Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the s s a significant threat to puoiic health and safety and the environment because one or more of the following conditions e Yes No the system is within 400 feet of a surf inking water supply the system is wi ' feet of a tributary to a surface drinking water supply _ e 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 consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: k Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant,or Board of Health.- _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The fa4il /o,-dv::Cir.g was inspected for signs of sewage back-up. t[ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. V _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. Existing information. Ex. Plan at B.O.H. A _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 or io SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: p.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: Garbage grinder (yes or no):_ Laundry connected to system(yes or no):_ Seasonal use (yes or no): Water meter readings, if available(last two(2)year usage(gpd): Sump Pump (yes or no):_ Last date of occupancy: 01/4r! rYt.'d�J COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or n _ Industrial Waste Ho ank present: (yes or no)_ Non-sani ste discharged to the Title 5 system: (yes or no)_ r meter readings, if available: Last data of occupancy: jTHER: D tL ate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) ILO If yes, volume pumped: eallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) f Q I (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: " (Locate on site plan) — Depth below grader Material of construction: _cast iron PVC_other(explain) 4 Distance from rivate water supply well or suction line s Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) L��a•�.-S ;7 i SEPTIC TANK:_ (locate on site plan) Depth below grade: /a . Material of construction: -.L/Concrete metal Fiberglass _Polyethylene—other(explain) If tank is metal. list age_ Is age confirmed by Certificate of Compliance (Yes/No) " Dimensions: fl Sludge depth: l Distance,from top off d e to bottom of outlet tee or baffle: Scum thickness: � Distance from top of scum to top of outlet tee or baffle: e- Distance from bottom of scum to bottom 9f_outlet tee baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relati n to outlet invert, structural integrity, evid ce of leakage, etc.) r qT �, r rv.✓7 0 •� fir. r .ice GREASE TRAP ;locate on site plan) Depth below grade:_ Z 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 to affle: Date of last pumping: Comments: (recommendatio pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidenc eakage, etc.) (revised 04125/97) Page 6 of 10 { i , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time, of inspectiort �G (locate on site plan) Depth below grade: Material of construction: _concrete_metal_Fiberglass_Polyethylene_other(e m) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in wor ' order_Yes;_No Date of previous pumping: Comments- (condition of inlet condition of alarm and float switches, etc.) ISTRIBMON BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: / (note if level and distribution is equal, evide ce of solids carryover, evidence of leakage into or out of box, etc.) n a'� 07 eyl 7i►P .'M P J //e--f O 4-'O 41,71 O� PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) C L Alarms in working order (Yes or Comments: (note con '' o pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: ' leaching pits, number:L leaching chambers, number:_ leaching galleries, number: leaching trenches, number.length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions pool: —Imaterils of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic ' ve of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/9) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record f Site(Abutting property, observation hole basement sum etc. Observationo S ( p ) i' � Y� Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) / D 1 �/f (revised 04/25/9'n Page to or to t�y�S��Stci�f 1 a iti r. utss bt Y '1'111e. COMMONWEALTH OF IN'IASSACHUSETTS 1)I�I'Alt'l'rvili'N'1' Oli UNVIItONMI1 N'I'AL PROTECTION BE, 1'I' KNO WN 'I'l1A't' Robert Lalime Ila% salislied 111e Ueparimenl's qualificaliuns as required and is hereby authorized to use the tide CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 C1v11L 15.34U and Section 13 or Chaplet- 21 n of Ille (;metal Laws. Issued by The I)cparLlncill of Filvironnlcnlal I'loleclion. it clor of Ipc 1 alon of 1Yn Pollution Control Oclober 30.1997 ....... Fizic ........... THE COMMONWEALTH OF MASSACHUSETTS V� BOARD HEAL tJ - ...oF...... ... .. ....... �C'�. .... ..... ............. Appliration -for 'Mip sal Works Tomitrurtion Vrrutit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal ystem at: \ . .�•.... •-••• __ - r -moo Address �J w Owner Address a Y[ .. .............. ...... _-----•--------- Installer Address UType of Building Size Lot---1,_7,,..27.,.3..Sq. feet Dwelling—No. of Bedrooms________ ______________________________Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other .._fixtures ___..._____....._____-------- W Design Flow____-_---�__.-0.........................gallons per person per day. Total daily flow------------------ . ........---gallons. 9 Septic Tank—Liquid capacit/6FG?V gallons Length................ Width_____.__._.--- Diameter_____..._...____ Depth_....._____._... Disposal Trench—No. ____ ______________ VV Tots ngth.................._. T 1 le Iing arca_.__1 �sq. ft. Seepage Pit No...... P --�Dl .... ow t... .............. iing area--------------._--sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...___.:______.___..... �TA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__.__._..__.__..____.__. Ix ---------------•--------------•-•••-•-•-•••--••-•----•------------•---....--•••-------•-••-•-•---•••-..................---------------------------------- ODescription of Soil--------- -------------------------------............................•-------------------------------------------------------------------------- -------•------•---_-- x W U Nature of Repairs or Alterations—Answer when applicable._.-___________________________________________________________________________________________. ---------------•--------------•----•---•-••-•--•-------------------------------•-----.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board f health. ` r ,/, Signed... l/ j Date ApplicationApproved By-------...•--•----------------•-•--•-•----•----•--•--•----• ------------------._---_--. •--- -----...........-- ....---------------- Date Application Disapproved for the following reasons:...............•--------------------------------.......-----------------------...-•------------•--•-•••••--•---- --------------------------------------------------------- -------------- Date PermitNo.---..................................................... Issued........................................................ Date No. -Jt. ....... Fia.... :'x'.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rr _...._.:_.....OF......,....:,-...........I......... . pphrtt#ion -fur Uiipusal Works Towi#rur#iutt Vrrnift Application is hereby made for a Permit to Construct (= '") or Repair ( ) an Individual Sewage Disposal System at:__4' ij -Location-Address / or Lot No. ...............................................................................................•-- ------------------------------•--........._...._.....------- -----------............... Owner i , Address Installer Address d Type of Building f Size Lot... _:__Sq. feet Dwelling—No. of Bedrooms------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ._._.-____________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ...�%--' -^--- W Design Flow.-_........ C) .......................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.. Seepage ft. Z Other Distribution box ( ) Dosing tank ( ) a .Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. I----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water------_--.__..-.--.----. �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.._.---_-__----------. P4 .......................----................................................................................................................................. ODescription 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 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. / Signed --------------- •--•-----------_-_--------------------_-------------------- Date ApplicationApproved By-------------------------------------------------------------------------t--------•----------_-- --------------------------------------- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- --••----•-••--------------••----•--••--•--••-•---------------•••-••-------••--••-••-•---••--•-•--••-•---_.. ................................ Date PermitNo........................................................ Issued........................................................ -Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Ter#if irate of Tilutplitturr THIS IS TO-CERTIFY, That .the Individual Sewage Disposal System constructed ;(�') or Repaired ( ) ------.. .------------- ------------------- - ------ -•---- � , � / �' Installer r •-••� ,.� at --•--•--------------------- ` = has been,installed in accordance with the provisions of Ar. I� XI of The State Sanitary Code as describ in the application for Disposal Works Construction Permit No._ -__-_5___�_............... dated.... ��_ ..."'.... __ ................. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA ISFACT0 \ DATE---------f ` •--- /--- em s"=-. Inspector.......... 2-'............................ ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o OF.................. ...------............................................... FEE........................... Di potial urk ( utt #rttr#iugt rriEti# Permission is hereby granted------------- _ ..._. . ._ _.//G <�✓� ------------------------------- .................................... to Construct (,,-)or Repair ( ) an Individual Sewage Disposal System at No.------- `` .�. - .r-,A -• ............................ -. - (- - - Street / � � / as shown on the application for Disposal Works Construction P it NO. -- ._ .... ated.... '_.-_____(_�..._..._.... V� * Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS _ �'1 • l1 • g k a-- � 44- 41 r�.. 149 3 EI-nC, rA fit.. 1 - (Cop [_Q L.E4f-- (-4 ?I'r' W l 't"t., 1 C7(} '�a '�.x p A U 5 I ors .`"• , ' v�- 1 C`. t<"C ►} �` I'l 'H.1• �'lI . t-OVIJDATiOO r>Wc,,Q1.J t �_.t`, k-1 ,z'• _- •r : , .t^ . .1. -,cL : �.�:�,:.►.fil'', oc- .�s Lam CoL,vr '3Z2Z 3 T►- 1 C-'!_�i} 1 I,�, 4. DT tllw O':,*VC=J'.\/►LUI c-, 11,`.%('i':)�.\�;�.:1' �/:.li:'•)'•.`i � "T"!-1`. _ ��4'i--'��1"tt �F.tt,U^,� ., � i t�l' ( i',., v',E.�3 i X'. `i�E�L./�t►!.Irr LC ; l_ �: PL1 C�►� tT CAPe 'De�, C PROffLE: NOT TO SCALE MR5T PIPE LENGTH �R 1 of :Vj PoLt � POP raLn r= co�R5 ro WITHIN ro m 6fr LEVEL PATE:�� t b' or rIN!�-ED 6RADE7 rCR MIN. V WASfitD 5r0� TE5T f)Y: Sul � �. G/ �•{'Y � rIN16ti W(>-NE55: PER(,RATE- -C Z.�-rin/��/C✓-� 'V /zoo hoc v s 4" `v,�O ray EL S , u� w buy ao e 1"` : C S ao 01VI 0 EL. SS,o �•; �1 �NQfM1 we a�rtt� .�� L_ �,. IN OUILG`"T[t PtST. �X S, Z , Mf I /00 VNI O LJN.117N SEPAF2/1r{ON f A •V'!:� µ � j` J" 39 s7o x,z � Q Lam✓ ' �A2S� G G G z, DE5 ION DATA � ado DAILY� FLO • (3)BEDROOMS x 119 GPD= 530 GPD SEPT L TANK:33a GRP x200%_(.O&PD LSE. v'GALLON PRE(A5T SEPTO TANK LEAGt11NGFA6lLf1-Y: . (,APAGITY: SIDEWAL.L: /vI�GEC Z;ro,75��' lsdp v OTTOM:_./. 8 xti 3 7',lv, _ .322, S � �� OENERAL NOTES 1 TOTAL`- CONTRACTOR TO 15E RE5PONSDLE FOR THE LOGATONOF ALL UT TES, y3 APOVE AND UNDERGROUND,PROR TO ANY EXGAVArON OR(,ON57RUGTON. o o b 2. SEPTL 5Y57EM TO 15E N5TALLED N GOMPLWNGE WIrM*V GMR PDO:Tfrl F V �►�C/STJ - �} C�/"' � .,� 3. 7H 5 PLAN 5 NOT TO PE USED FOR PROPERTY LNE DETERMNATON 71. GONTRA(,TOR TO PROVDE 24 tiOUR NOT(,E FOR ANY REQURED N5PE670N5 -o 0 N /o o c> L�•5 T' C7- / D• 1 000 /_D , O SITNf LA L.OGATION: /Z7 � cq _ ,�/ �� • �o�• o PREPARED FOR: DRAWN �,Y- 4 - 3� o y' DANIEL E. STEVEN $ BR WAN J0f5 NWf5ER: DATE._ u.,il— /8 2oa3 341=: o RU 5 9 �p�v CIVIL„ 32686 3 S� t'QF S�A P TF`GISTtV SUR SNAL Ea G_ c3 ��3 r VVELLEF'\ A�5�5061& I ATE J(o45 FALMOIJrM RD - SUITE 4( OENTERVILLE, MA OUn TEL.: (508) 775-0736 N FAX: (508) 775-0754 FROFE5510NAL ENGINEERS & LAND SURVEYORS