HomeMy WebLinkAbout0086 SCUDDER ROAD - Health 86 SCUDDER ROAD, OSTERVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^
�
86 Scudder Road, WIT
V
Property Address fi
Lauren Cronin
Owner Owners Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection w
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 Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key. - -
374 Route 130
�a Company Address
Sandwich Ma 02563
City/Town State Zip Code
rxcv (508)477-0653 S113747
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 r
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by.thelocal Approving Authority
4. ❑ Fails
> 11-6-18
Inspector's Si ature 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
cf Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 86 Scudder Road
�V
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
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:),
X I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.The dwelling has a garbage grinder and the system
is not designed for it. It is recommended that the grinder be removed to prolong the life of the SAS.
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):.E
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road ;
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
St
page. City/Town ate 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):
r
❑ 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.
y
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
V�
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
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
El 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
❑ O 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
i
Commonwealth of Massachusetts
f , Title 5 Official Inspection Form t
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
86 Scudder Road
L.-
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.) -
Yes No
❑ El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ElLiquid depth in cesspool is less than 6"below invert or available volume is less
than '/day flow
❑ El Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑- El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or.
tributary to a surface water supply.
❑ El Any portion of a cesspool or privy.is within a Zone 1 of a public water supply
well.
g
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ID 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.]
❑ E The system is a cesspool serving a facility with a design flow of 2000 gpd
10,000 gpd.
El The system fails. I have determined that one or more of the above failure
El 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
❑ El Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
86 Scudder Road
V�
Property Address
Lauren Cronin
Owner Owners Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact"the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes ' No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El 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?
❑ a Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ E Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ El 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:
El ❑ Existing information. For example, a plan at the Board of Health.
El ❑ 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
I
Commonwealth of Massachusetts ' t
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments'
86 Scudder Road
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18 '
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: r
3 Number of bedrooms(design): Number of bedrooms (actual): 3
' • 330/gpd
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
3 bedrooms per permit dated 12-3-76.
Number of current residents:
Does residence have a garbage grinder? Yes ❑ ,No
Does residence have a water treatment unit? . ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection Yes 0 No
information in this report.)
Laundry system inspected? ° ❑ Yes,0 No
Seasonaluse? 0 Yes ❑ No
See below
Water meter readings, if available (last 2 years usage(gpd)): i
_ Detail:
"`2016-10,042gallons 2017-10,042galIons"'
Sump pump? + ❑ Yes ❑■ No
Last date of occupancy: Oct-2018
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
V, Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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: Owner- Last pumped summer 2018
Was system pumped as part of the inspection? ❑ Yes X No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�m Title 5 Official inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
Property Address
Lauren Cronin
Owner Owner's Name
information is Osteryille Ma 02655 11-6-18
required for every
page. City/Town -St-ate' Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system t
❑ Single cesspool
❑ Overflow cesspool
. . 3
❑' 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:
1976 per permit -
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
21
Depth below grade:
feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
l5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
86 Scudder Road
v
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: 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
1
Dimensions: 000gallons
511
Sludge depth:
311f
Distance from top of sludge to bottom of outlet tee or baffle
Orr
Scum thickness
NS
Distance from top of scum to top of outlet tee or baffle
NS
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
Property Address
Lauren Cronin -
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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.):
r-
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
u-
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
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.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0"
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts '
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
v
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code ' Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes No"
Alarms in working order: ❑'Yes No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* 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: f '
• t
Type
(1 ) 6'X6'
El leaching pits number:
❑ 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.7/262018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 18
� i '
c� Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l;
86 Scudder Road
V
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
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.):
The leaching was in working order and was dry with a stain line 1/2 way up from bottom at time of inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
t
; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
G
r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
u-
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
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:
❑Q hand-sketch in the area below
❑ drawing attached separately
Asbuilt Ground Water Profile
Grade
2'
Rear $,
A
6'x6'pit
8 >11'
Al-20'
A2.27'
A3.34'
A4-43'
3 81.IT >31
B2.14'
B3.1T
64.27
Ground water
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
i
Commonwealth of Massachusetts
�d I Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
Property Address
Lauren Cronin
Owner Owner's Name
information is required for every Osterville Ma 02655 11-6-18
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: No GW @ 11'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: ,Date
El Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
see below
❑ Checked with local excavators, installers-,(attach documentation)
E Accessed USGS database-explain:
see below
You must describe how you established the high ground water elevation:
USGS topo maps and charts showed ground water is greater than 15'. A hand hole was also
augured to a,depth of 11'.(3',below SAS) and no ground water was encountered.
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
f II
Commonwealth of Massachusetts
Frm
. Title 5 Official Inspection0
I�
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Road
v�
Property Address
Lauren Cronin
Owner Owner's Name
information is Osterville Ma 02655 11-6-18
required for every
page. Y P
City/Town/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 in contract attached d
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
l5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
f
-�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owners Name
information is Osterville Ma 02655 3/30/2012
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.
Important:When A. General Information
filling out forms
on the computer, "'f
use only the tab 1. Inspector: //
key to move your
cursor-do not Sean M. Jones '
use the return
key. Name of Inspector
C y e Enterprises
&y Company Name
153 Commercial St.
Company Address
Mashpee Ma 02649 -
Cityrrown State Zip Code
508-477-887-7 SI 4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
�M
3/30/2012
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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if apWi6idI j&d the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future,under
the same or differp4 conditions=of useZ
x, 1 1 U7 l
t5ins•11110 TNe 5 Official Inspection Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. Macl-achian
Owner Owner's Name
information is Osterville Ma 02655 3/30/2012
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Y ❑ N ❑ ND (Explain below):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
- Commonwealth of Massachusetts
Title 5 Official . Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. Macl-achian
Owner Owner's Name
information is required for Osterville Ma 02655 . 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipes)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):
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health): ..
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ �Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health: ;.-
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1..System will pass_unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts l
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
I El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No ,
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any,portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion iof a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area--IWPA) or a mapped Zone Il of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
N, Commonwealth of Massachusetts s
u Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
For example, Ian at the Board of Health.
Existing information o e ,
® ❑ 9 P P
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
86 Scudder Rd w
Property Address 3
The Estate of Suzanne H. MacLachian'
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder?, ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] „ ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years.usage (gpd)): . .
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: ,s, ~ unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.;etc.):
Grease trap present? , ❑ Yes ❑ No
Industrial waste holding tank present?. ❑ Yes ❑ No
Non-sanitary waste'discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts 1
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy -
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts „
Title 5 Official Inspection Form. .
Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
86 Scudder Rd
Property Address .
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma •02655 . 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? a ❑ Yes ® No
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: 10+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade' 1
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: 511
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. City[rown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3.5'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
` 10"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years as
maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was
intact and in good condition.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction: .
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
., gallons
Design Flow:
gallons per day ,
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts - s
- Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box was functioning as intended.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working I order: ❑ Yes ❑ No
I
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type.
® leaching pits number: 1, 1000 gallons
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found to be dry with no signs of past hydraulic overloading
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
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts s
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. Maci-achian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
L Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 86 Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is r
required for every OSteNllle Ma 02655 3/30/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a viemi 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
F
o �e 2 O f �-f OVJ6
p
A-f 2 Z' d 3 '
A-2-
3 p
►3-Z y
AS 39
/3-3 17
/3'Y Z2
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts u
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M •''rt 86.Scudder Rd
Property Address
The Estate of Suzanne H. MacLachian
Owner Owner's Name
information is Osterville Ma 02655 3/30/2012
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
,
Estimated depth to high ground water: 20+feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground_water elevation:
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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
86 Scudder Rd
Property Address
The Estate of Suzanne H. Macl-achian
Owner Owner's Name
information is required for Osterville Ma 02655 3/30/2012
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
s COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTEC I�
ONE WINTER STREET, BOSTON MA 02108 (617) 292-550
WILLIAM F.WELD ��C® TR Y COXE
Governor 'A Secretary
3 1
ARGEO PAUL CELLUCCI � A R HS
Lt. Governor Q Pr .BARor STAStr . C•
69 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z
PART A
CERTIFICATION
Property Address: $b SGu�Oct2. �.�OSTEav�\\� Address of Owner: jPvtzq.r_ °$�w1 Qy'A\e,-�41tvL
Date of Inspection: S\.5\\Cx7 (If different)
Name of Inspector: M.c o
Company Name, Address and Telephone Number:
RTLA•,sTtiC_ Ew:v%cc .v�� rs� ,�t•o�b� a��y rins, _t Mra. oZ�.-�q CS-" L�17-1�aZa
CERTIFICATION STATEMENT
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
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority. w
_ Fails Inspector's Signature:-,"1 &(A-A_�, Date: 313�\r
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 inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D: _
A] SYSTEM PASSES: ,
—1 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, 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 11/03/95) 1
A
i� Printed on Recycled Paper
L '
P
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
i' CERTIFICATION (continued)
Pr ert'
p Y
Owner: o
Date of Inspection:
B] SYSTEMCONDITIONALLY ASSES (continued)
Sewage backup or breakout or high static water level observed in the distributio ox is due to broken or obstructed
pipe(s) orfdue o a broken, settled or uneven distribution box. The system wil pass inspection if(with approval of the
• I Board o;yea th):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to b ken.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 HEALT
Conditions exist which require further evaluation by the Boar 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 DET MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a su ace water
Cesspool or privy is within 50 feet of a rdering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MAN ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank d soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system'has a septic to and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic t nk and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septi tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a ell water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution om that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
3) OTHER
(revised 11/03/95) 2
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as d in' in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to d rmine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded r clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to n overloaded or.clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or availabl volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT d e to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or rivy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet f a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zo I of a public well.
Any portion of a cesspool or privy is within 5 feet of a private water supply well.
Any portion of a cesspool or privy is less t n 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the ell has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic comp unds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large cyst s in addition to the criteria above:
The system serves a facility with a de gn flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the env ronment because one or more of the following conditions exist:
the system is within 40 feet of a surface drinking water supply
the system is withi 200 feet of a tributary to a surface drinking water supply
the system is to ted in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water s ply well)
The owner or operator of any ch system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5. 0 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
c '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: $6 _GWOOtQ_
Owner:
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the 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 facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
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.
4-The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: $to 5CU04 q—
Owner: G)pkk!"�-tn- " .. . •
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 510 eallons
Number of bedrooms: 03
Number of current residents:__!�o
Garbage grinder (yes or no):_gD
Laundry connected to system (yes or no):—%5
Seasonal use (yes or no): 00 _
Water meter readings, if available: ..,a LGw i�sac�c_
Last date of occupancy: SAvn(rACLS
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NI K1, i
System pumped as part of inspection: (yes or no)_!�D
If yes, volume pumped: Qallons
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 'r �ku
Sewage odors detected when arriving at the site: (yes or no)�p
(revised 11/03/95) 5
R
l
r-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: s(o SCU plc 2
Owner: �SlwllgmjMtl,
Date of Inspection: 3`31�r1)
SEPTIC TANK: v_...�5
(locate on site plan)
Depth below grade: l2y
Material of construction: X concrete _metal _FRP —other(explain)
Dimensions:I WO(VIA
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: 34u
Scum thickness: O"
Distance from top of scum to top of outlet tee or baffle: 164
Distance from bottom of scum to bottom of outlet tee or baffle:-11,
Comments:
(recommendation for pumping, condition of inl t and outlet tees or baffles„depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) 0 N"P4,S k N Iw1
v 1 J2d) wa
GREASE TRAP:__Oc�
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
SYSTEM INFORMATION (continued)
Property Address: $b 9D31bC3eC
Owner: �c�
Date of Inspection `3���,
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: eallons/day
Alarm level: '
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:WLS
(locate on site plan)
Depth of liquid level above outlet invert: s
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of.pumps and appurtenances, etc.)
(revised 11/03/95) 7
:l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: q"�► OL - .
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_LtGS
(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: AWL
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic fail re, level of ponding, condition of vegetation,etc.)
C. Sk9tns z�—ky&aLA%c_ _Qk.I\U4-2- S,L"�1MrtrQ M62VM
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:lib
(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.)
(revised 11/03/95) 8
n
.o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '� O4erZ,
Owner:rggllCc�lv.,�,
Date of Inspection: a\s%\
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
1GG O•o—
Z
a0 \s
133—
DEPTH TO GROUNDWATER
Depth to groundwater: 1\ feet t
method of determination or approximation: LQcjtC ODk 4--Ch , A�pk Vpyy --� 6
3 �.r.a
(revised 11/03/95) 9
µ TOWN OF BARNSTABLE
LiAT ON _ -- SEWAGE
ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I(X>0 I r.-
LEACHING FACILITY: (type) IW O e4- (size)
NO.OF BEDROOMS
BUILDER FOR OWNER
�DATE: I COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by ��,�
r
P 1A
A3 y3y 1-t
f.
• I
LOCATION SEWAGE PERMIT NO.-
VILLAGE � s -5c0,®oF-¢
INSTA LLER'S NAME & ADDRESS
e
B .UItDE-R. OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
9r � �� l 6' f �9
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No......\a4�...... FRx...............................
............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.....OF.. .e . ....................
Appliratian -for Biopood Marko Tonotrurtion Prrutit
Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
......................... ..................................................................................................
Location-Address or Lot No.
j 41-o C-5 C, I-A-6/V472 F_(_
.................................................................................................. ............CC(./,Opc7z 'ec�,av 0t,7r7ei//i-i—a—
......................................................................................
Owner Address
"37M *0
........ gv.Z�679
................... . .. ...................................................
Installer Address
Type of Building Size Lot-."1,3/�6!-----------Sq. feet
U
Dwelling—No. of Bedrooms..--_---3...............................Expansion Attic Garbage Grinder
aOther—Type of Building No. of persons---------------------------- Showers Cafeteria
Otherfixtures -----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow..--......�Kcll...........................gallons per person per day. Total daily flow 30o
WI- ------------------------------------------.-gallons.
P4 Septic Tank—Liquid capacitvP�,_gallons Length----�........ Width......Y_...... Diameter---------------- Depth---Y-----------
Disposal Trench—No. .................... Width..........._.----_-. Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No......... .......... Diameter._.-_--6-1-------- Depth below inlet.....G-'........... Total leaching area.��C5--------sq. f t.
Other Distribution box (>e ) Dosing tank ( ) -,- I
Percolation Test Results Performed by.--_-- ---6Y Date----------------------------------------
Test Pit No. 1-----------_--minutesperinch Depth of Test Pit-------------------- Depth to ground water....-.-_----------.----.
�Zq Test Pit No. 2----------------lui utes per inch Depth of Test Pit.................... Depth,to ground water-..--.-.---.---------_-.
---------------------------------------------------------------------------------------------------------------------------
0 Description of Soil------..- ....4:4�_ ............................................................................... -------------------------I---------------------
U ..................................................................................................................................................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicab, -----e�PR?��Q, C 44 C, i C_7--
Y
--------_- ----- ........ . ----------
- ---------
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 eration until a Certificate of Compliance has been issued y board of health.
-)Sign 3 oac 7&
e ............ . .................................................................. ........------------------
Date
Application Approved By--- ----------- .. ..
Date
Application Disapproved for the following reasons:...................... ..................................................
........................................................................................................I-----------------------------------------------------------------------------------------------
Date
PermitNo........................................................ Issued.------....----------- .................................
Date
., ., t •
No................ ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA TH
� .... ..._.OF....JC� .Gin
Appliratiun -for Bilipogttl Workii Cnonstrurtion Permit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
••-•--. - ----------•-------------------------•--•--------•..._------ ----------------------------------------------.....------•-••-----------------------••-----------
Location-Address or Lot No.
t 4.4-6 hxcr L E S Gtli7l9t72 ,!Irk GSTZ� i!/LL4—
..............................�---•---•-----•------------------•---•----....-..--------------.... •--��-- .... ... --
Owner Address
/�®i..t3 .�.._. tJ4. JNC. Gk'cls�T.. c,�ts'S7-Z►.i�'N �Q ....... .......
� Installer Address
d Type of Building Size ----------Sq. feet
U Dwelling—No. of Bedrooms------3..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building of persons___________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures --------- -------------------------------------------- --------------
W Design Flow___-___�0-----------------------------gallons per person per day. Total daily flow______-�tUO---------------------------
WSeptic Tank—Liquid capaclty.t.i;'N?gallons Length_-_-_V._-.._.. Widtli.----V........ Diameter_-..- ---------- Deptli..`'_.........
x Disposal Trench—No- -------------------- Width___----__--._-_--__ Total Length-.---____-._.._---_. Total leaching area------------.-------sq. ft.
-
Seepage Pit No--------------------- Diameter-_____ ----- Depth below inlet--_-.4............ Total leaching area__ZG_ --------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.__ !�� ...�'y-__ '-j -----°�-._.1 ? Date---------------------------------------
Test Pit No. 1________________nunutes per inch Depth of "Pest Pit.................... Depth to ground water.__-------..--..__.____.
f4 Test Pit No. 2................m utes per inch Depth of Test Pit..------_-_____-_-_- Depth to ground water---------4------------
a' ..
------- --
x ---- ------------------------.----------------....-----------------------------------•------.
� Description of Soil--------- ---- — -----r_-•------------------------------------------------------------------------------------------- --------------------------
W
V Nature of Repairs or Alterations—Answer when applical�e...�' ...�??v! --'�`-......` !�L C c;'�y�<�cr'
- ----
.�,�_ -
_�'-_7?.�_----�R:i_sn!yG--------�-°�_r7.G------�_X-57.z?_"1�•----• ----' - -�:`J---�j�c�J-�•�.-r-•--�--�-�--- --- =----- •--.....
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the oard of health.
7 Sign- _.r C lG -
Date
Application Approved By- `� --••�Gti1/j ._---••- � _. .../y76
�J Date
Application Disapproved for the following reasons:
--------------------------------------------•• -----•---------------•-----------•----------------•--•----------------------------------------------------•-•----------------•---------------------_-----
Date
PermitNo......................................................... Issued......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
n_ BOARD OE HEALTH
�'... ............OF........ ... �.
rr#if irate of Q'I'lImptianrr
I IS C IFY, T t e Individual Sewage Disposal System constructed ( ) or Repaired �Y
by-. �' -•---- •. ---------------- - ;'
,}jIry�t
all
erf '/T, //��J
at_.. --- - -- ----- --------------- -------------------- -------
ha. een installed in accordance w* the provisions of ArV XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No- --- -----------. �'_ .... dated._-./!z_=.3.'.7�•e%__--_-•-.--_.._-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE----------/= V`---•-- Inspector-- --- c-----•------------------•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
........I� �. ........OF......... . .. ........... a-.J
No.........................
n FEE
�i4rurt ion Permit
Permission is herebyranted__.-.___IiL�C1- _..____IZL ..�'.�`'�-_. `
g -------------- ------•-
to Constru ( or Re pa; ) n div- 1 e ge Disq osal System
� Street
as shown on the application for Disposal Works Constructi/' O?Ml*t N -------
-_ Dated_.._ 2.— _' ............
DATE Board of Health
/`tom - ----------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS-
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