HomeMy WebLinkAbout0025 RENOIR DRIVE - Health 25 Renoir Drive
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Commonwealth of Massachusetts ,r;z�; ''r4(o
Title 5 Official- lnspection-forin
l l Subsurface Sewage Disposal System,Form Not for VoluntaryiAssessments;-i0?,;o
T >' 25 Renoir Dr
Property Address iy, a
Susan Quinn r, ! -
Owner Owner's Name ,
information is /
required for every Osterville, •�:. n MA 02655 3-13-21 Xr-"
page. City/Town a,•, 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.
A. Inspector Information s 1 ,is a
Shawn Mcelroy
Name of Inspector 1"J`..>i•I,4•,{ .,.+. C i,a., At
r 'Upper Cape Septic ses rvice Ct
Company Name V . °• •'' ',
P.O. Box 73 .t- ,tr. 'I,,—
Company Address
East Falmouth t `1f' y N' ' r,.1 ,t•-.-pt>MAmi,ri o. ,,t, ,- 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:) 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•thepoperty 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
emaintenance of on-site'sewage disposal systems:After conducting•thi's inspection'l have determined that
the system: ;.+
y®"!Passe91`,1 1(''l 1ar� , i i?s�� li .i•ir1,3 + �"� c: w'C .. '�'? - `1 t.
2. ,❑, Conditionally Passes #r
.. .!L•:. •1'.1 .. .k 'C) Tx r:$, i 4r,. - A-f:.' 3
rt ',.. � �1!"..• f�.'i 11 fi - !'+1tt: r ..,: lr- ..R':' r! R•`+•ir ''�.`.r'Ws..i +� ,M'I�IK.. .2,r
f❑ *NeedsFFurther Evaluation,byahe Local Approving Authority, f;1 ; X •,
4. ❑ Fails
io e + .a i' r ii 1
ftf.:'+?w 4°=t ; .:•fi. Syr}3!;,44 3^ ►>r • �..Z
_ 1 3-13-21
Inspector's Signature "Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the .
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/2 612 01 8 ,, ;r , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18-
Commonwealth of Massachusetts
oo
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
` 25 Renoir Dr w,
�J-
Property Address
Susan Quinn i
Owner Owner's Name
information is osterville I MA 02655 3-13-21
required for every -
page. City/Town a 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 r
indicated below. ,+
Comments: '
4( -
System is in good working order with no sign of failure. '+'r•: '
VI T.Y r i S
r 2) System Conditionally Passes:
❑ One or more system,components as described in the "ConditionalPass" 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. r
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): ,
t r '
a
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
• Commonwealth of Massachusettst
Title 5 Official. inspection Form.,
KI1 Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments.:Fr ,�=,
25 Renoir Dr
Property Address
Susan Quinn ,�;•:�. ; ,,_
Owner Owner's Name
information is required for every Osterville - ?, ; A MA 02655 3-13-21
page. City/Town , t ,, a State Zip Code Date of Inspection
C. Inspection Summary(cont.) f • y, ' I ,�
2) System Conditionally Passes (cont.): '
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired`
j.L±. ,. -�#jY7•, �,. . .j'r . ,L• �r...•y .'�:t 't; it; Lr,. -cr
I!':�:'.� " l"�i. y:r "-.`_:3;st?•} 44..J i rf1;:rf3! i€:. "f•e .4i.g:'E.e �. . i,.,�'t3�{ rr� .t<.i9 i':'"Ilr 'r'+e,i
❑ Observation of sewage backup or break out or highlstatic 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
ass ins^ection if(with a` roval of Board'&Health)'
P P PP
'I if ❑ '' broken pipe'(s)are replaced !J'i *'Ji • '0T'Y•`❑N ''=I❑Y'ND (Explain below):
ET' ' ' Lobstrtaction is�removed ' '?11, '•'...t °I;❑ Y & ❑N tr" Ell'ND (Explain below):
• ❑a t Aistributidn-66xi is`leveled or replaced '❑YM dtE]fNl?TT,ND (Explain below):
A a
•h 1{' i:F, ,.ui"i 1 1•'1 .. t�••.J $'i ter � ;'1•..ye' Ffi t� .': • ,�_n .f. ! �,'. 3 rt � :. 3: t i; J'f'bJ [. � t♦
.., ^ , rl� , _ :, Zr. .r }.� s..,t�- n^ ir. , i � - n !' . •c.s •!'. r. t�f:r. s, .1r
�?. .:.1• :s rrA'"rZ. .7�,, 5f J cr+"..7�3 rr.l�"`�' J+'�"1 ,1 i .:�: ..`-'Stj,'r - "'YJ'� I '",�`f�� ",F? '. ""'9lyi
❑ 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 El ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of,Health:,, 4;j 9l
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the systi3m'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: ' L
r.4 u}`y't JY., ,;eJ4�y. ;-�*�. +i��.' -C: )f err ...,.1' It - !�.t�,.{ '!.fir fl,'�..%.A '.
t5insp.doc•rev.7/26/2018 s „ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18, • s, ,
Commonwealth of Massachusetts
Title 5 Officual I ' ' pectio •for `
r01 Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
.gip [ad
K
25 Renoir Dr -
Property Address t
Susan Quinn t
Owner Owner's Name
information is Osterville ` t MA 02655 3-13-21
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 4 I
❑ 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: 21
❑The systemihas 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. Y
❑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: _ J.
4) System Failure Criteria'Applicable to All Systems; '-,
, W . . .,C, AYou 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
t5ir:sp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
1
Commonwealth of Massachusetts - ,r ,�� tw-;,;,�; ,-�;,s,,,:x,:1,�* •,,,.: '
Title 5 OfficialInspection �Foem
rol Subsurface Sewage.Disposal System Form;-Not,fortVoluntary.Assessments;�
>�M 25 Renoir Dr
Property Address
Susan Quinn $x,,, q ,�
Owner Owner's Name
information is
required for every Osteiville .r•..; An! MA 02655 3-13-21
page. City/Town ,_, State Zip Code Date of Inspection
C. Inspection Summary (cont.)
t• J-41)I,System Failure Criteria Applicable to,All Systems: (cont.)
:I; rw)P,_Up �'rf��011 r'Y 1.J 1a .!e(1.I #f,
Yes No . �,.. +1 F
_. .. (r .. EtLr y-)s., C+'�t' 3i,,{ ,f�1t�a�'i1�1." a,. �"'-'C�� .�:ltCl: i,•7 ( ' ..'*Rf' �i 1a3 f a.r.{"l.l�j5•'r:i `.-rj l! a
r" '. ►1= ,�r'.:� i ...r ., .'• t r! e..{� M, '+ r.n'4- 1•
Staticliquidlevel.inthe distribution box above outlet invent due to an overloaded
❑ ® to `o'r'clogged SAS or'cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
:n FT.-: .® �o @than''%Zday flow..,r,�Yc1 *)'"a ' m '2_,., r�. Jot :a�lr, �� ' c
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
'obstructed pipe(s). Number of times pumped:
i 1 . ,. + , ,n❑ ,r ®,� • 3;Any portion of the SAS;,cesspool,or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
`r; r�a� ;'apt t";t,ftttributary to a surface water supply: L A—
d, Any portion of a cesspool or privy is within a Zone 1 of a public water supply
•-� .� r.., ,❑ .,1�:,i®.: l+'well'.�l a�17 awl '.; . . ,,�,:�lr�;,.
'o` ,T .❑`L ® 1""' tAny$'bitior''of'a cesspoof`or privy iswithin 50 feet of a private water supply well.
1, s lol
` r' '�` y ` ^��'.°'t •�'r , t ¢'aAny'portion of a'cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with'rio acceptable water quality analysis. [This
"It,) -J ,,; . . ? p-I rtt.{ ;system passes if,the well,water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
t ;lof 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
_}_ ,04 !• �, 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-
,.! si 'r�t+�,� f�� ^.ti❑, ®��ta 10;000 gpd` a ,m ` -M �
, . . �. � . �.
The system fails:I.hatve' deter'mined that one or more of the above failure
ep'Acn ena exist 6s'des6ri6e'd in 3f0 CMRf15.303,therefore the system fails. The
!q tt; : E, rCtL?„.f 1.1 . ,+ .system,owner,should pontact the Board of Health to determine what will be
c` N i ,s nKv" ;w,{;r,,k ,fi ;recessary,to correct the,failure.',„w,ti,•. =
s.
.i , %tl `H'fir,:.i'� 'f1=rd�'.� f'�IiV,'+OVr'A t3{tG G•��..,r P'G�.;.3>;rr�l, �1g7I: -..;,:C3:1�
''�^^ '3'a4:y'ft I~.':.'•'r:l`�,i.r5 t�.fisa,+
5){ Large Systems:To be considered a large system the systemmust serve a facility with a design
I flow of 10,'060 gpd to'15 000 gpd. iv•' ' ';"''T'`''+''tlr,=f;,•�
-For large systems, you,,must indicate either."yes;'a or,"no;'ito each of the following, in addition to the
.questions,iniSection CA;�.5 ;,a, �+ , ,:aa : t, at�'at,wa1l;4a'
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone 11 of a public water supply well
t5insp.doc•rev.7128/2018 „,.* Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18., ,
Commonwealth of Massachusetts
Title 5 Official. Inspection, F®rhi r
Subsurface Sewage Disposal System Form--Not for Voluntary Assessments '
25 Renoir Dr
Property Address
Susan Quinn
Owner Owner's Name
information is required for every osterville - MA 02655 3-13-21 '
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) tJ
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 7following for an inspections:
Yes No
® ❑ r 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
El, ® 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 corriponents;'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,
ap dimensions, depth of liquid,',depth of sludge and depth of scum?
tE ❑ 'Wasthe 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.
❑ r' Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310'CMR15.302(5)]
,
t5irsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts ,,
y
a y Title 5 Offi.cial Inspection Ford .$;
r.•
h.
► Subsurface Sewage Disposal System Form;-'Not for;Voluntary Assessments,
25 Renoir Dr
Property Address
Susan Quinn
Owner Owner's Name k, E
information is
required for every Osterville MA 02655
page. City/Town T, • , �„ , • ;. State 'Zip Code Date of Inspection
D. System Information ,t ,1",, " . +
1. Residential Flow Conditions: ',;nfrlt:=-,` +:•^i �:.tJL t.?rfi -2 a';€ `41
Number of bedrooms (design): N/A Number.of;bedrooms(actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd•x#,of bedrooms)_ N/A
Description:
• - • ?, n,� ; . ,!` "fit,r I , .,,.,�
ST
Number of current residents:
• i Does residence have a garbage grinder?,rs y 4,,p r,:,t,,r , ,, ; • ,. ;,,.,�. , .+ ❑ Yes ® No
Does residence have a water treatment unit? {; ,;a,,.,�, ur. ,.:, ;o,?n, .. r j „' ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection_ Yes ® No
information in this report.) '. °� ' L t.` ,; t` ' ` i y
Laundry system inspected? - ❑ Yes ® No
Seasonal use? - _ ❑ Yes ® No
Water meter readings, if available last 2 ears usage d '
9 ( Y 9 (gp ))� -
Detail:
Sump pump? a , n ; .r; .a� 4 �ri ❑ Yes ® No
, yJ
Last date of occupancy: ,�. 3-2021
Date
t5insp.doc rev.7/26/2018 1. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page of 18,.- q
Commonwealth of Massachusetts t ' t'-
rvi `y� Title 5 Offil6laH n'spects®n Forte , { ;r " "I
' III) Subsurface Sewage Disposal System Form--Not for-Voluntary Assessments
25 Renoir Dr AA
Property Address
Susan Quinn
Owner Owner's Name
information is Osterville '{� MA 02655 3-13-21 ti
required for every ?
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) • ' - 1
2. Commercial/Industrial Flow Conditions:
'.Type of Establishment:
Design flow(based on 310 CMR 15.203): - `` '' ' .A ft
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? ' P ''' l'' ` ` ` ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? -' '-°r # n ' El Yes El No
Water meter readings, if available:
Last date of occupancy/use: ' ' ' '
Date
Other(describe below): % t
1
3. Pumping Records:
Source of information: Owner----pumped 2020
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
.AL IN.
Commonwealth of Massachusetts e,,-?u :
�+1.
;. Title S Official, Intpe' dioa� ,Fo .N
I. Subsurface Sewage.Disposal System Form•-Not for Voluntary Assessments ;
� %<r
25 Renoir Dr _.. t•r ��r• :�
Property Address 4 A
Susan Quinn n tr
Owner Owner's Name
information is Osterville:~ t,; .t MA 02655 3-13-21 v
required for every •=
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system 1 • ► J
❑ Single cesspool •� ,,,,,,;,, ,t,
i.,, . .� +_ ❑:� .,t. {-• 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, }
.. , ❑z,,. , , Tight tank:Attach a copy;of the DEP approval.
❑ ' `' 4rr`i f Other(describe):
Approximate-age of all components; date installed.(if known) and source of information'
1984
Were sewage,odors detected,when arriving,at theisite?,,,, c; *: .a j. ;.,❑ Yes ® No
5. Building Sewer(locateFon site plan): , •,.,J
18"
Depth below grade: r �� rr = t a.;�..,. feet
Materiaf of construction:'�IvD 4 ; P,'r
❑ cast iron- '"''..lI ®40'PVC'",
Distance from private water supply well or suction line: feet
Comments on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official I fspec$ionfo
IQ Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments' '
25 Renoir Dr >
Property Address -
Susan Quinn t
Owner Owner's Name
information is MA 02655 ill sterve 3-13-21
required for every Ci f
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '-
6. Septic Tank (locate on site plan):
Depth below grade: ' '_ " " 12"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El'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: , ,r, r, 1000 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle `' 26'
Scum thickness 0
Distance from top of scum to'top of outlet tee or baffle - •
6"
Distance from bottom of scum to bottom of outlet tee or baffle' 16" ,
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage. --
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts ;Y ,; +, ��•� z �,
TitleOfficial Inspection i`or
Subsurface Sewa a Disposal S stem.Form•-Notfor,Voluntar yAssessments
a t '
r K,
25 Renoir Dr
Property Address t; ,
Susan Quinn
Owner Owner's Name
information is
required for every Osterville MA 02655 3-13-21
page. City/Town . �� State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan): t _ } , *,14 i t•'�t#,+,,� .�, ; ,;,
Depth below grade: r ;-J feet +• ,..:
Material of,construction.:- ;,r
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene,.;._ ❑ other(explain):
r3 k`•r.: r rf .•six tf. 1,,c+.t,c,:l;,3.+.. 'dt•..i : - i
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
y .Date of last pumping: i r
,. P P _g:Ir i t �,,,, :�; •tf n� ,,tt .tutl . 1 "0 Date'°}.: -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of feakage, etc): ' � `' ;`'' °•�''
ti ,". .i�r. , , .� ;, #` !.r-s k�I�;.-.- "� . ,i, nf�.A' r -"' n �.,'•;f - c,r, It
' ,•, -+ , ,,, --r• �''r: n, . t,,; .�--- `„ .r r, ii::.+>'�+ 4, fF'<r�rt?i, ,•..,r,rt ' •t:..
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.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 - ,w
Commonwealth of Massachusetts
�s Title 5 Official Inspection for'r`
wa
Y-I Subsurface Sewage Disposal System Form-Not for Vol u ntary'Assessments
r. >' 25 Renoir Dr
Property Address
Susan Quinn er, '
Owner Owner's Name
information is Osterville MA 02655 3-13-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
B. Tight or Holding Tank (cont.) y == ►' ''
Alarm present: ❑ Yes '❑ No'*O
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.):
Good condition with water at working level and no sign of back-up from pit.
. 4
i
9"W ."",I
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts r ' ,-; a . r �••_
a f0 Title 5 Official Onspe.c$ioh F.om
iQ Subsurface Sewage Disposal System Form.-;'Not forVol u nta Assessments 1, ',t s `
25 Renoir Dr
Property Address ,
Susan Quinn ,
Owner Owner's Name
information is
required for every Osterville .• a ,;;, MA 02655 3-13-21, ,
page. City/Town 4 State Zip Code Date of Inspection
D. System Information (cont.) ,,,,, ; ► „� ;4 •{
10. Pump Chamber(locate on site plan): ( r. r` •,< < ;��;° rf„� , P
,
Purrips'in working order:,: .. 1.,, °;fir 1LJ r; :.�c Io ro i,r,rdl -;W1 v❑~ Yesr° ❑ No*
i g ii r *i'3•>° t y �i`a' )o Jil: i,i J ;.. '� Yes j ❑ No*
Alarms in workin `order:
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
hi Wu ,yjr,} i. ..i; •ne•i ,ti `.. - . i.',F.�Cd,;.YJ- lu+-.c a .°
* 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): ,j
If SAS not located, explain why:
Type: 1` ,t z,,r -F •_
. 'Wit i 4 •"'. .4. )il � C i :.a, f
t. al
IeaCliing pl4s'' :r:i ` d { : ''�" ` `riu'mber:`'r f ifr!i " 1-1000 g
qe il�
❑ leaching chambers number:
❑ leaching galleries number:
leaching trenches - number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.,7/26/2018,, ,, t• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 .
Commonwealth of Massachusetts - r'
r� 00 1'i$1e 5 Oacaa8 Bnspectoon Forhi
�IQ Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments
° _= > 25 Renoir Dr
Property Address "
Susan Quinn
Owner Owner's Name
information is MA 02655 Osterville t ' 3-13-21
required for every �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.) #,rr1
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and holding 24" of water with stain line,at 36" below inlet invert.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration-
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
!
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 '
r
Commonwealth of Massachusetts
ra p Title 5 Official. 1nspec$ioh. Foft.
r�i Subsurface Sewage Disposal System Form -Not for,Vol
� _ ,
�r-�, 25 Renoir Dr
Property Address
Susan Quinn
Owner Owner's Name
information is
required for every Osterville- MA 02655 3-13-21
page. City/Town; ,. M. 1 State Zip Code Date of Inspection
D. System Information(cont.) , .. , •�; ;.:;, { ; . .,
13. Privy(locate on site plan): '• i• �° _ `" `�# " `Cj .
! i,•`A4P :3114 F. .V!Iof r..
°Materials of construction: , top ++�' L ~n ,r•s+'.*•.
Dimensions
Depth of solids -
Comments (note condition of soil,signs of hydraulic•failure,'level of pofiding, condition of vegetation,
etc.):
•t
i
r i
a - rj F4
r
t5insp.doc•rev.W28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 .
Commonwealth of Massachusetts ' "
Mi Subsurface Sewage Disposal System Form"-Not for Voluntary Assessments
25 Renoir Dr
Property Address
Susan Quinn 1 3
Owner Owner's Name
information is Osterville MA 02655 3-13-21
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) R.+
14. Sketch Of Sewage Disposal System: . . : ... ,P ,,•, ,
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
a
:
. . 4
A-A
L/
3
+ 6j .. k..
j
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
r
Commonwealth of Massachusetts _ ;: r,, --.,., c,
3 Tide 5 Official Inspectio� Foti
-1 1
ri Subsurface Sewage Disposal.System.Form;Not,for,Voluntary Assessments
25 Renoir Dr 10 1.) = `:'
Property Address ,4, e
Susan Quinn
Owner Owner's Name
information is
required for every Osterville r•,, MA 02655 3-13-21 ,
page. City/Town -,f .I,,W State Zip Code Date of Inspection r
D. System Information (cont:}: 1 .:: ,tC=
15. Site Exam: ;v fVt z.A.).1#rr.;r L0. W 4,t n•i�i.4i,qI ti c:cls,-t r.%;,,
❑ Check Slope n, ,;`{ r fi i ti �t't~T If: ,+ ,fr#y t,t
❑ Surface water ,,. 'v, Ij �~ .P ,r, ".,C ri
❑ Check cellar
❑ Shallow wells ntill,I IM a1MM t •, if
Estimated depth to high ground water%_ ,,7�i��, r?;,1,� �,:,,. ;`t feet''`
Please indicate all methods used to determine the high ground,waterl,elevation:C--
❑ Obtained from_system,design.plans on record b;irk#
.,tj.)E.;If,checked;,date,of,design plan reviewed:,Fy. ,Dater
Observed site,(abutting property/observation,hole within•1,50,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:
USGS and town maps show groundwater at greaater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018, ,, 3 .- Title 5'Official Inspection Form:Subsurface Sewage Disposal System-Page 17,of 18 - J.
Commonwealth of Massachusetts
s Tile 5 Official Inspection Form
-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
y 1.7
25 Renoir Dr
Property Address
Susan Quinn
Owner Owner's Name
information is Osterville - - MA 02655 3-13-21
required for every '
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist ,,-,
Complete all applicable sections of this form inclusive of: .r
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ' • "�''
® C. Inspection Summary: .•te- -
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed 3 -
® D.'System Information:
For 8: Tight/Holding Tank"Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg A 6 or attached
For 15: Explanation of estimated depth to high groundwater included
144' 1 r. '.♦
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
NO- .Y ..7.. .. Fxa............._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4o !1 . OF.................13
Appliratiou for Uhipmal Works Cfnnilrurtinn Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•3•--- r�-� /.......•DII&_.............•..--------.. -- . .... ...... �.�_/...:....
Lo tion• ddress or Lot N.
......................-•••............. ��1r�i.......�7 : /L........--• ... _v_�G .... .r.,? B,K S...l.._L�........
O Address
W ... -eo ............ � F 5 �...v�.�................. "�-
,-�
Installer' Address
Type of Building Size Lot...
[ 1.0......Sq. feet
U ....................Ex Expansion Attic Garbage Grinder,..., Dwelling— No. of Bedrooms..................... . p (K.�ji g
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ........------------------------- ..
W Design Flow........................3D -.---------gallons per person per day. Total daily flow.............. .Q...............gallons.
x Septic Tank—Liquid capacity.//OO.gdllons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------------;______. iameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( Dosing tank
'~ Percolation Test Results Performed by...........................
--- Date........
Test Pit No. 1....4-YSt-.minutes per inch Depth of Test Pit........}fry..... Depth to ground water.........
GL, Test Pit No. 2..._644..rminutes per inch Depth of Test Pit.................... Depth to ground water........................
L...................................................... � ...............,r.
..---- .. . } .�....0o Description of Soil.................................................................... ..............•-----I--- ----- .... .
,.
VW �s----- 42.............................. -'------------- •••••---•
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'ITLE 5 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 t oard of healt
Sid....... ...............
i�� te
ApplicationApproved By.... ... •----------------------•---•••-•--•••--•--............------------_-_.... ...��� f... ..............
Date
Application Disapprov or t following reasons:...................................................................... .........................................
--.....---•---••-•---•..............................•---•--------•---•-----..............--.......-•-•--------......................•---•----•---------•------•-•-•-•--- ----_......_---•----••••••--
Date
PermitNo........................................................ Issued.......................................................
Date
...... u. �. ----------
No. ......._ .... FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
HEALTH
.-......0F............:....�/ 14 �r`'
Appliratinn for Diipuial Workii Tonstrnrtinn Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--Y--•--------------------------- CJ : . �_......•.:.............................. ............. ............................. .5.Z......
Lo ddress or Lot No
S Address
Installer Address
UType of Building Size Lot... � a 6!0..._..Sq. feet
Dwelling.—No. of Bedrooms.........................................Expansion Attic (Ate)Z', Garbage Grinder e--I�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ............................................................... -
W Design Flow.........................>... ...........gallons per person per day. Total daily flow............. .%. ...............gallons.
1:4 Septic Tank—Liquid capacity.,/.Z)0.g lions Length---------------- Width................ Diameter................ Depth................
Disposal Trench—No..................._.. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________-_.___.Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (/) Dosing tank
Percolation Test Results Performed by------•..................... r `� Date ) �:.f L_. .....
1 > j --
Test Pit No. 1....!�'?"I�._minutes per inch Depth of Test Pit........It?..... Depth to ground water..__......"'`-_.__.
(14 Test Pit No. 2.._� t'�niinutes per inch Depth of Test Pit.................... Depth to ground water........................
•-- ....
O Description of Soil...................................................................0........Z-- " 4�! } . �� � �
"
-••-••••-•-•••••••••------•••••••••._...-•-•-•-••-•....••..................... - --•V
i
VNature of Repairs or Alterations—Answer when applicable................................................................................................
.............•••••••---•-••-----••-•••--•••-••••-•----•-•-•-...•••---......•....-•-•--.........•-•----•--•---••---•----•----••-••-•--••••......•....••--•-•-•••--•••••--•-•-......---..............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 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 '
...................4 '� ��
Application Approved BYC ��400
..............
�9 Date
Application Disapproved for tie following reasons:
..-•....................................--•--------------------------...---•-----••---•---.......---------•-•--•-•-........---•••-----•••--•-••--...•••----••----•-•••-•---•••--•••-----•-•.........-----
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
- 7-
BOARD OF HEALTH
er,s ✓ �=
........OF................ 't.:..........'`?"................................
Trrfif iratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,<) or Repaired ( )
. ........ •-----------------------------
at 1 �Z._ Installer
......-•-•--.... /^ � .1!---------------
has been installed in accordance with the provisions of T T�''F��'' r of The State Sanitary �o�../as scribed in the
application for Disposal Works Construction Permit No, _.'.. ................ date d_t' _ - ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM W L YUNCTION SATISFACTORY.
DATE..19 ...1 ....................................................... Inspector.... ... ,........-----------•--••------------•-----........--•--...-----•---•--.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE. .................
�un��rnr#irrn �ertttit
Permission is hereby granted---•----------------- _�' 'r`'- -....... �� ✓ -! .................................
to Construct ( *or Repair ( ) an Individual Sewage Disposal System �
15*
- - -• a- •...------
//.._.. ...-1 Street �^ '
as shown on the application for Disposal Works Construction Permit No: � Dated/✓, ._ � ...............
c�
Board of Health
DATE / ----....•--......
FORM 1255 A. M. SULKIN, INC., BOSTON
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LEGEND CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION Ox0
EXISTING CONTOUR --- 0 -'- �� ��•, L v-� •'� x�'e'�,"v! 1:;� E
FINISHED SPOT ELEVATION ��'"/Rcefr?
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DATE AGENT '�1iIJ,+titj4 SCALE, � _ �U DATES
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_ LD}�'E'DGE ENGINEERING CO. IN
_ _._ CLIENT . I CERTIFY THAT THE PROPOSED
REGISTERED JOB NO. 6Z�2- �� BUILDING SHOWNON THIS PLAN
CIVIL LAND n, CONFORMS TO THE ZONING LAWS
[!EGISTERE
'NGI(VErk SURVEY R DR.BY �� OF BARNSTASLE , MAS ' .
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712 MAIN STREET CH. BY, �
s�HYANN I S, MASS. SHEET_LOF - -
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