HomeMy WebLinkAbout0150 SEA VIEW AVENUE - Health 150 SEA VIEW AVENUE, OSTERVILLE
°A` 162020
�S
_ TOWN OF BARNSTABLE Ira
fL�iC ATION SC:AV I Gt� JAAL SEWAGE #
VILLAGE OsrZ1"Ja( ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I USSP6b I
LEACHING FACILITY: (type) (A) (size)
NO.OF BEDROOMS J
BUILDER OR OWNER gAtr!j 7A C.
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac 'ng facility) Feet
Furnished by TA-Mc as D!G'I
t�cwc wey
---------------------
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TOWN OF BARNSTABLE
LOCATION Z 0 6 e A V M SEWAGE #
r
VILLAGES ASSESSOR'S MAP &LOT Z O C7
I INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS-I"
BUILDER OR OWNER' 1�'R —Tp,v F
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet f leachin facili ) Feet
Furnished by _� Gl 9
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TOWN OF BARNS ABLE
LOCATION l`7® 'ee, SEWAGE #
VILLAGE, 1�i9�� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY&
LEACHING FACILITY: (type) s` (size)
NO.OF BEDROOMS e
BUILDER OR OWNERagWe
�i'J� 3
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) r14— Feet
Edge of Wetland and Lea4ng Faciliy(If any we ds a
within 300 feet o ea n f ty) '� Feet
Furnished by
i 66
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1�
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i
Town ofBa
r ))0P arhR0aa$ofPegwatoay sawces ;
na 200 Maia StTrrc,Hyannis MA 02601
pate Scheduledj/��1 'I zx�e F'oe 1Pd,
-w
u > z Su&,dhU1tyAsse&Me ; �
p
PerFoa�ncd By: � 5i +
Wztnessed`Hy>
LO CA T+t�I�T (; t .�Cr:7C r"+ r
L❑cabn Addre;;s
C
r 0.
• D J �e�VI I LL° „A�ddZH55 •
/ t j P i• `
Assossor's Map/�'arcel: �602�20
NEW CONS'TRUC•IMAI REPAIR Teiephone k S( 3 b�V4 ,
`f
��
• Land Uso: Alt" �,,.a�f� �` gI❑pcs(9G) S,urFaae Skones •
Distances flvm: open Water Body-�- "--L l?ossihla Wet—Area Drinking Water Well �+ft AMI
Drainage Way �• ft Property Line — ft Other ft
dimensions❑f-, exa a❑ations❑ttesthdl s 8c' orc tests ❑cake wetlands o i '. c
P ,] w an s n Fx x zaity to hol s)
Parent rnatecial(gcologic) �" c1 � `� Depth tv Bod ck
Depth'to Groundwater. StandingWaterin H,51c:�9 Woepingfrortl PitFpna .
• r
Lstirgated Seasonal S lgh Groundwater
C 2, TA`1[ ON FOR SEASONALtIGR WATE rJ�'ABLR•
Method Used 1
Depth Observed standing in obs.hole: __ ___--la, . 1`reptlzlts?•SQLI NNt W-,_
Dagth to wcepingf'rom side of oba.hole: ln,. Groundwater cljuumant
Index Well•f# Rcadiug DAtc: Indent WelllpYQl .Ad,�,ttr»tdr, R dJ.:(i1Guiltlwutet'1
Observation .
Halo it � '1 lxnp•at:S1" �,m _,
Depth o1 Pezn. - - Tllrta m is"
Start Pre-soak'Timo @ t. e `i'ima V141)
s
RateMin:Iincli
SltgsultablIlly,A.eacasnarut. 94o)?fiuod AddidonaI`I'ostfngNeeded(• )N)
Original: Publin Health Dlylsloa Qbnorkdau Holp Data To Bo Coznpxnted on Back---� -_
**"'If percola dbu testis to be emadueted vaitblu I00' of we-laud�you must first-a.otify the
Barnstable Couso> vado)a Division at-least oaae(1)Week prior to beglrwlug�
Q-,)S'RPTTCIPI3RCFORM,.00C bQr
Dnpthiiom SdIlHorizon Soil.Texturc ShclColor Sail.. Other
Smfacn(in.) , {i> bA} (NiunseIi) Mottling' (Structure, Stoned;boulders,
• }( o i'toncy,,_°/a'Cr�.yei1 '
{` tt
D _4 VOIDS VATIONT[Mg LOG ' Role# •Z
Depth from Soll.rrorizon S'oiI Texture Soil Color Soil. 06'r
Surface(in.) UUSDA) (munsnll) Mottling (Strarturn,Stonm,boulders.
onsis len 90 Grave
.��
DEFT 01BBERM&TION ROLE M)
; Rl ---
Depth*oui SoilHorizon SoiITaxtura Soil Color Soil Mar'
Surface(in.) (USDA) (1Jlunscli) Mottling (Structaxo)Stones,boulders.
t Collul9toTim Omni)
DREP OBSERVA,.7CION 11012 7LOram:' Role 9
Dopth-1ram soil Rod= SoilToxturc soil Color Soil C3Yhcr
Snrfam(in.} (USDA) (Mansell) Mottling (5tructurn,SfoRm"Boulders,
• •J s Ca si tdn 6 ,
d /{ 61131
�'lond 7xasrr�'anc���a.•t�_1V.Ctape. • .
Above 500•year;floodboundary No— Yaa \\,, ,,,,
Within 500 ycarboundary. Nox 'Yes -
Within 100 year flood boundary No.x 'Yds
Detytla bf Mderlal .
Does at least four Feat of naturally occurring porvious .pwrisl oxist iti ail areas nbs6r,ved throughout th6
area proposed for the soil absorption systaml L `
`+• {
If not,What is the depth of naturally Occurring pg ous.edirial'
Q;ert"igication h� � ',
x certify that on .3 ..(date)x havapassed the soil evaluator examination approved by the
Depaitmorit Of$nvlronmental Protection and thartho above anaTysis was porformed by isre consistent with .
'the required trainin expertitle and experience described In�10 CUR 15.017.
• , �ignafure baf� . .
Commonwealth of Massachusetts
'' -• � Title 5 Official Ins ecti
p on Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
a 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name
✓/
required for every Osterville MA 02655 2/24/2017
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, r�VJ '
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return
key. Name of Inspector
Ford Septic Services, LLC
rn Company Name
P.O. Box 49
Company Address
°m Osterville MA
City/Town 508-862-9400 02655
State Zip Code
_ S 12482
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 Furth r valuation by the Local Approving Authority
2/27/17
Inspec s Signature Date
The s em inspector shall submit a copy of this inspection report to the Approving Authority(Board
of He or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow,of 10„000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
\0116d VS
Commonwealth of Massachusetts
` Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•` 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name
required for every Osterville MA 02655 2/24/2017
page. City/To wn State Zi Code
P Date of Inspection
B. Certification (Cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found.any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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):
15ins-3/13-
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
l
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner Owner's Name
information is
required for every Osterville page. City/Town MA 02655 2/24/2017
State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber Pumps/alarms not operational. System will ass wit
Pumps/alarms are repaired. p h Board of Health approval if
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y 0 N ❑ ND below):
lain Ex
( p e ow):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health): '
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) . Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a borderingvegetated 9 etated wetland or a salt marsh
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Seaview Avenue
Property Address '
Gregg & Kate Lemkau
Owner Owner's Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone-1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
15ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
f
i
Commonwealth of Massachusetts .
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
150 Seaview Avenue
Property Address '
Gregg & Kate Lemkau
Owner Owner's Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/Town State ZipCode
Date of Inspection
B. Certification (Cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
' tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water'supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,. "
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 MR 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
0 El the system is within 200 feet of a tributary to a surface drinking water supply
❑ the,system is located in a nitrogen sensitive area"(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply PP Y 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. ,
(Sins•3113 y
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name
required for every Osterville MA 02655 2/24/2017
page. City/Town State Zi Code
P 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?
Z ❑ Was'the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ -Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms n/a
(design): Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`M ••'•t 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name
required for every Osterville MA 02655 2/24/2017
page. City/Town State Zi Code P 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? (Include laundry system inspection
information in this report.) j ❑ Yes ® No
Laundry system inspected?
❑ .Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump?
❑ .Yes ® No
Last date of occupancy: unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments
a,••'• 150 Seaview Avenue
Property Address '
Gregg& Kate Lemkau
Owner Owner's Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? El Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Seaview Avenue -
Property Address
Gregg & Kate Lemkau
Owner Owners Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/Town State ZipCode
Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Cesspools -original
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on,condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
El 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:
Sludge depth:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name
required for every Osterville MA 02655 2/24/2017
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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`
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.):
Grease Trap (locate on site plan):
Depth below grade: n/a
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
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
�c a
•'•y< 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name
required for every Osterville MA 02655 2/24/2017
page. City/Town State Zi Code
P 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 ❑ fiber lass
9 El polyethylene El other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes "❑ No
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Seavi ew Avenue ,.
P ro ert p y Address
Gregg & Kate Lemkau
Owner information is Owner's Name
required for every Osterville MA 02655 2/24/2017
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
Pump Chamber(locate on site plan):
Pumps in working order: El Yes El No"
Alarms in working order: ❑ Yes
❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
a
" If pumps or alarms are not in working order, system is a conditional pass.,
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
V Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
A,• 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner Owners Name
information is
required for every Osterville MA 02655 2/24/2017
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type.
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,.condition of
vegetation, etc.):
The overflow Cesspool was 6'w x 7't x 9' btg and was dry. It was made of brick and the steel cover
was to grade just under the bark mulch. There was no sign of failure. ***Note to owner/buyer the
.cover is next to the electric meter just off the driveway. Care should be taken not to drive off over the
cobblestone curb and onto the covers. The cesspools are not rated to be driven over. The driveway
seems to have been added many years ago.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 with overflow
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer 4"
Dimensions of cesspool 6'w x 81 x 10' btq.
Materials of construction brick with steel cover to
.grade
Indication of groundwater.inflow ❑ Yes ® No
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
v s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�A 9,•`'�r 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner Owners Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
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.):
N/a
t5ins•3/13 -
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�,•`°t 150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner information is Owner's Name ;
required for every Osterville MA 02655 2/24/2017 page. City/Town State ZipCode
Date of Inspection
D. System Information (cost.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Li
QA�
Dctvc.wAy • /�
l ,
i
S
a 1el Q9
l5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
p n Form
Subsurface Sewage Disposal System Form -Y Not for Vo
luntary
Asse
ssments
essments
150 Seaview Avenue
Property Address
Gregg & Kate Lemkau
Owner Owner's Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/I own State Zi Code
P Date of Inspection
D. System Information,(cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 18'+/-
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:
Topo and water contours map.
❑ Checked with local excavators, installers=(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts'
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
150 Seaview Avenue `
Property Address
Gregg & Kate Lemkau
Owner Owner's Name
information is
required for every Osterville MA 02655 2/24/2017
page. City/Town State. Zip Code Date of Inspection
n
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
f
fl Commonwealth of Massachusetts
Ti b 5 Official Inspection Form
Subsurbee:Sewage dal System Form-Not:for Voluntary Assessmer ft
15 Sea View Ave., Osterville
AP -N 162 020
Owner owres fame Bryon & Heather Corsini
requiratfo s 6501 .Wilmett Road �2�?j 0 7
tequved'for
evmpw- CWTOM Bethesda, MA 20817 !Code Dam of
Inspection resets,must be submitted on this form.inspection fauns may not be a#tered in any
way-
out A. General Information
forms on the
cornputer,.use 1. Inspector
a*the tab key
to move your
cursor-do trot
use the return
key
Engineering Works Peter T. McEntee P.E.
W. 12 West Crossfield,Road Title 5 System Inspector. _
Forestdale, MA 02644 Lic. No. S11480
Yefephom Number License Nurr of P-3
•ATM'
e�
t� �)
B. GertifiCatiE?n
t
1 certify that 1 have pemona#y inspected the sewage disposal system at teas Wi#hat tt ?
information:repcxted below is true,accurate and complete as of the time of fine i :Tate ecrt:
was performed based on my training and expe€ientce in the proper function and maint fmce own site�,,,,;-
sewage d4msat systems:I am a QEP approved system inspector pursuant to Sei ton 15 ofp
Title 5.(310 CARR 15.000).The system:
❑ Conditionally Passes ❑ Faits
❑ Needs Further Evaluation by the Local Approving Aut!iority
Inspectors signature
6
The system inspector shall submit a copy of this inspection report to the Approving Auffuo€ty(Board
of Reafth or DEP)within 30 days of oornpMnq fats Wisperfion,if the system is a shared system or
has a design flow of 10,000 go or greater„the inspector and,the system owner shall submit the
report to the app€c priate€egiorral office of the DER The original shoutd be sent to thee system m me€
and copies sent to the buyer,if applicable,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address to the system will perform in the future under
the same or different conditions of use.
mkaps fte•tltm TZO6OMWUq) -"FOW sUlem'Ptoft5
Commonwealth of Massachusetts k
it nspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
159 Sea View Ave., Osterville-
Property Address APN 162-020
Ovvmr .. ors r&= Bryon & Heather Corsini
i`fO1mtionis 6501 Wilmett Road J ZI G �'-7
required for
every page. Wrom Bethesda, MA 20817 ,ZpCede oate of his
B. Cerfification.(cont)
Inspection Summary check A,B,e,D or E/always complete at#of Section D
A) 71have
asses::not f oundd any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 GMR 15.304 exist.Any failure criteria not evaluated are
indicated Wow
Comments.
LA
��P�ltm /lrtJ /Iezd L/G ? (/��t7'�✓ . l/S�6
5 Avald Le
B) System Conditionally Passes: .
0 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,wilt:pass.
Aram yes,no or not determined(Y•N,ND)in the[I for the following statements_#fano€
determined please explain..
n The septic tank is metal and over 20}tears old`or the septic tang(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 triftating that tfte tank is less than 20 years old is available..
ND Exptain:
' 0. Observation of sewage backup or break out or high static water level in the distribution box due
-to broken or wed pipes)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with.approval of Board of Heath):
broken pipe(s)are replaced
rl obstruction is removed
t5ursp dac•0=6 Tfe5 OfficW trot Fam Subwz1amS9azW DsgasaE9pstpam•PW 2 of 15
Convnonwealth of Massachusetts
Te 5-Official Inspection Form
Subsurface face Sewage:'Di isposaI System;Form-Not for Voluntary Assessments
159 Sea View Ave.,Osterville
Property Adaie_ APN 162-020
Omsk ads Nam Bryon& Heather Corsini
Infarrmfmis 6501 Wilmett Roadrequirod for -2.
CWTO .Bethesda, MA 20817
Zip Gale• LnMat'UMPMwn -.
B. certification (cont)
B) System conditionally Passes(cant.j:
❑ distribution box.is leveled or replaced
ND Explain:
n The system required pumping more than 4 times a year due to broken or obstructed pipes). The
system will pass inspection if(with approval of the Board of Health)_
❑ broken pipe(s)are replaced
obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
0 Conditions exist which require further evaluation by the Board of Heart in order to determine ff
the system is fairing 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 function tg in.a manner which w0l protect public health,
safety and the environment:
Gesspool:or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,.
safety and environment:
The system has aseptic tank.and soil absorption system(SAS)and.the SAS is wittuin
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 welf
l5utsp doc•�R6 T&5 Sri al hasped=Ran Subs hce Soymge Dispmt System•Page 3 or 15
IZI>\ a�'.v7uTiv�ivrCackri vi in"aS$a�.isiiacu"a" "
Fite 5 Official Inspection Form
JUFsauFFac.cJcVrwyt FJFJF/V.7aL JrJ1.GFLF F VFFFF rVV(!Vr V VlUrRQIY!•Y37r."T711IGr/W
159 Sea View Ave.,Osterville
Pmnartv_ArtArwcc APN 162-020
r awmr's Nam Bryon-& Heather Corsini
Informadon is 6501 Wilmett Road Z.
reauired.for
evety page- CiwTavyn Bethesda, MA 20817 �rtp;Code 001ti Of k4ectrof, .
B. CeMficaban (mint.)
C1 further Evaluation is Reauired by the Board of Health fcw*-I:
1n_7-. Tti�vJ ate.rir iuca a v.�..fliiv—1.1-1—yr w uriu-uFi�vs w— i'vca.�a i;1-1.•�vv—I---�vi vi
more from a private water supply well**
Method used to determine distance:
Thic cvctam mccac it tha wall water analvcic nPrfnrmPri at a nFP Cerfif!ed lahomtnrv, for nnlifnrm
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than b ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Uttter
v
ul System Failure Criteria Appiicabie to Aff Systems:
You nuist indKm a"Yes"or"No"to each of the following for all inspectkms:
Yam Mn
Q 2/1"_ Backup of sewage into facility or system component due to overloaded or
/ clogged SAS or cesspool
uisui►atye of put lull ty ui eiIlueui to ute Sul ldue vi ule gtuuttu of Sutiat:e waieis
due to an overloaded or Flogged SAS or cesspool
j�Static liquid level in the distribution box above outlet invert due to an overloaded
6 or clogged Sim or cesspool
U / I ion iirl rianth in rascnnni is iPcc than W hPlnw invvat nr await hlP vnillmP is IPgc
ly' _ — r_. ... - --
than%day flow
1 Required pumping more than 4 times in the last year NOT'due to coed or.
obstructed pipe(s).Number of times pumped`
Any portion of the SAS,cesspool or privy is below high ground water elevation.
u ,-,/ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5assp doc-98ID6 Tft 5 MW MVed=F=r.Sutsrdm Sewage Dftosal S}atem-Page 4 of 15
is
` �U
n..... —VLtYMcp
. ..-...,eaff&a. ..0 aw......,.,.�.......sa..
t✓i7# IIlu9 vl Mallkoutraluoutto
Tip 5 Official Ins co Form.
.-. - 0..M......6www-0... w:n Gw _ 1 C..-*-m Co.- KI-4 fr..�[..t....i.s... n....,..,......,.,,4..
vuW.luafaVc Vcww c.V.i.7wvGi'PyovG/i1 i i III-Plwk.7Vr P %Iliigiy nJJCJJulcnw
159 Sea View Ave., Osterville
om'""fi'Address APN 162-020
r 0t z:`S Elk Bryon & Heather Corsini
infoEma�an.is 6501 Wilmett Road /Z�
requited Bethesda MA 20817
every page
- CitylTown •. , Zip Code Qate�pe '
B. Gerfificatian (cont.)
D) System Failure Criteria Applicable to All Systems(cant.):
Yes No
Li ice Any portion of a cesspool or privy is vAhin a Zane 1 of a public well
U. Any nortinn of a naccnnnl or nrivv ig within R6 facet of a nrivata water cttnniv
w2ff.
Any portion of a cesspool or privy is less than 1€0 feet but greater flan 50 feet
from a nrivntp watpr ctinnty wpii with no arrantahtP watpr rkttartty nnatvcic frhic
.._... -,...____ --r.r'I ..-.. ..._....- ----r----._ 'i--..y -..._.J_._. L....._
system passes it the well water analysts,performed at a DEP°certified
taboratmryt for fecal coliform bacteria indictees 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 attd to this form.]
u rJ The c,,rgfem fc w Cgs cnnn! #TazIQX �f'?!lt]llnsv(
1G,000gpd
u The system fails.t hose determined that ore or more of the above fad•re
criteria exist as described in 310 CMR 15.303.therefore the system fails.The
sySaiC owner s_uutu VLkt aU the nU_Q_E4 U r ek1 Gdft t zt oUetC_t-nine 1LC_tt wl ie bC necessary to co.ntthe failure.
` ' v_s t-ms: o b aside 4 a iav__...-...+. z the e......4am fraust.�aa...race $��i th
:.�ryc' J;stC:i.... T.s� ..°..,i...�,.�u. ...ycv�.�.i.�..':3:c.c......f3i,..,.i, - ¢�.r°O. - :lt$`yr3dtu.aa.
design flow of 10,000 gpd to 15,000 gpd. A//4
Cnr Loma�trcta. r.nyr mrwt irivivM.wto aktiar°i.ar•°yr°riv°tv-E-h—ftk-ra f-/kv,i;_g it vvvitivr:iv the
questions in.Section D:
Yes NO
tine system is within 4UU?eet or a su"-ce drinking water Gippiy
Lf 0' • the system is within 200 feet of a tributary to a surface dfink rig water supply
the cvctem is lilnatM in a nitrnnan c.Pn.,gMva area 1 interim WPllhpaft Prntpntinn
Area'—rVVPA)or a mapped Zone it of a pumic water supply weii
if you have answered'yes"to any question in Section E the system is considered a significant threat,
or an_Swerart"vac"in SPP.tinn n ahnva the►nmP cv0Pm hag failarf Thin own or nr-K-rafnr of anv lamp
system considered a significant threat under Section E or fatted udder Section D shall upgrade the
-system in accordance with 31-0 ffMR 15.3041.The system owner should conatact f-.-appropriate
vegionai of oe of lire Depa-ftment.
t5insp.dm•OM6 T-de 5 OracW t[wedon Foan:Subsu face Ser age Disposal Syshem•Page 5 of 15
Commonwealth.of Massachusetts
`itte 5 Qffi
oiai Inspection Forrn
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
159 Sea View Ave., OsterviHe
Property.Address APN 162-020
Owner OwnersAwne. Bryon &:Heather.C.orsini
Information is 6501 W lmett Road f Z` -7 0�7
required for Bethesda, MA 20817
every page. City/Town , 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?
:[jj/ ❑ Were as built plans of the system obtained and examined?(If they were not.
available note as NIA)
[ ❑. 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:.
❑ Exisffng-information. For example, a plan at the Board of Health.
❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 GMR 15.302(5)]
t5lMp doc•006 Title 5 MOW Inspecllon Forth:Subsudace Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Titt QfifiGiat Inspection Form
Subsurface Sewage Disposal System Form--Not.for Voluntary Assessments
159 Sea View Ave., Osterville
Property Address APN 162-020
Bryon-& Heather.Corsini..
Owner C*m es Name
inforrtation is 6501 Wilmett Road
required for Bethesda MA 20817
every-page. City/Town , ,Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
pit de .,�, �-
Number of bedrooms(design): jq ��ry�lmber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder? �es ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] Q Yes OAN o
Laundry system inspected? 9-"�es ❑ No.
Seasonal use? ❑ Yes 0 o
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes Vo
Last date of occupancy: cats
3
CommerciaUlndustrial Flow Conditions: N`rT
Type of Establishment
Design flow(based on 310 CMR 15.203): Gallons per day(go)
Basis of design flow(seats/persons/sq.ft., etc.): ,
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe):
t5insp doc-0=6 Trde 6 O(fldal Irspection Form:Subsudace Sewage Disposal System•Page 7 d 15
Commonwealth of:Massachusetts
Tithe 5 �fficiat Inspection Form
Subsurtace Sewage<Disposal System Form Not for Voluntary Assessments
159 Sea View Ave., Osterville
Property Address APN 162-020
Owner Owners Name Bryon,& Heather Corsini
i"f°""a"°"IS 6501 Wilrnett Road r Zj-Z
required for
everypage. Citylt°wn \Bethesda, MA 20817 lip Code Date of)nspedion
D. System Information (cunt.)
General Information
Pumping Records:
L��ti�✓ci�4 LC
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
� y
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous.inspection records, if any)
❑ Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank Attach a copy of the DEP approval.
❑ Other(describe):,
Approximate age of all,components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes M1<0
Mnsp doe-OW6 Title 6 Official lrgxxWn Foam:Subsudece Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
159 Sea View Ave., Osterville
Property Address APN 1.62-020'
- .Bryon.& Heather Cors.ini
information Owner's Neme
is 6501 Wilmett Road . ' ,7 k-7
required for Be 20817
thesda MA
every page. City/Fown + �-p Code Date ot,lnspection
A System.Information (cons)
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction: °
[]cast iron 40 PVC ❑other(explain):
Distance from private water supply well or suction line: et ��
feet '
Comments(on condition of joints,venting, evidence of leakage, etc.):
Septic Tank(locate on site plan): (fQ S.S'aoa1 'qc. 'rz Jn q S .S�-4`"c Jec r Lz
Depth below grade: A � ��0(4
feet
Material of construction:
❑concrete ❑metal (]fiberglass ❑polyethylene ❑other(explain)
f3 t7' C L<
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
3 `f
Scum thickness Pone-
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? ��
t5fnsp.doc-006 Title 6 Official Inspection Form:Subsurtace Sewage Disposal Systam-Page 9 or 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.system Form-'Not for Voluntary Assessments
159 Sea View Ave., Osterville
Property Address APN 162-020
Owner ownees.Narm Bryon-& Heather Corsini
inforrnabonis 6501 Wilmett Road
regwred:for Q
every page. City/Town Bethesda, MA 20817 ;Zip Code Date;of I io
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.):
7+ Vl 6 M to CYU 4--U+ /rt>i! 7' ' t $6'itO M _J-�O I n 4 P-- ltV l
V
nd
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
El concrete 0 metal ❑fiberglass ❑polyethylene other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle ,
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.).-
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade; ,
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
- 5 v..
t5insp.doc•OW6 Trde.5 Offlcial Inspectlon Form:Subsurface Sawa Dis I ge posa System•Page 10 of 16
Commonwealth.-of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
159 Sea View Ave., Osterville
Propeny;Address APN 162-020
,Bryon..& Heather Corsini
Owner owrler's,Name 6501 Wilmett Road / Z.l-7 f information is l 0-7
required for Bethesda MA 20817
every"page.. Cityrrown , Zip Code Date ofanspecbon
D System Information_(cont.)
Tight.or Holding Tank(cunt.) /j h-, ,
Dimensions:
Capacity:
gallons
Design Flow.
Satlons per day
Alarm present ❑ Yes ❑ No
Alarm level: Alarm in working order: _ ❑ Yes- ❑ No
Date of last pumping Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened)(locate on site plan ���- 1rl
.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.):
Pump Chamber(locate on site plan): AJ�f+
Pumps in working order. ❑ Yes ❑ No
Alarms in working order. ❑ Yes.'. ❑f No
t5inspdoc•08A6 - Title 5 Ortlrial Inspection r-on:SubsuRace Sewage Dlspml System•Page 11 of 15
I
Commonwealth-of-Massachusetts
Tate 5 Officia t:nspect on Form
Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments
159 Sea View Ave.,Osterville
Property Address, APN 162-020
1ff1e� Bryon &.Heather Corsini
Owner's Name
information is 6501 Wilmett Road
`egt,ired 6r c Bethesda MA 20817 2
every,page. City/Town , Zip Code Date of Inipetfidn
D. System Information (cunt.)
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:
�0►i-F.� �I Gi
Type:
❑ leaching pits number.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
overflow cesspool x ! number:
❑ innovativetaltemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
�� 9
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t5lnsp.cft•DUG Title 5 0171dal Ins Form:Subsudace Sewage Disposal System•Page 12 or 15
I
Commonwealth of Massachusetts
Title 5 Offical inspection Form
Subsurface$"9e Disposal System.Form-Not for Voluntary Assessments
159 Sea View Ave., Osterville
Property.-Address, APN 162-020
Bryon_& Heather.Corsini
Infor
Owner owrter's,Name 6501 Wilmett Road
requirmation is
every gage. Bethesda MA 20817
every page. City/7ovm ,Bethesda, Zip Code Date of Inspection
D. System Information (cunt.) VIA No It cesJ,,�pt?-o l�
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool ,
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5irmp doc•08M Title 5 Official I rrspecton Form:Subsurface sewage Disposal System•Page 13 of 15
Commonwealth of.Massachusetts
Title 5 Official inspection Form
Sutsurfac e;Sewag&Disposal.Sysiem Form-Not:for Voluntary Assessments
159 Sea View Ave:,Osterville
!�oPeny aaaless
"N 162-020
Bryon..& Heather Corsini
Owner Owner s'NIar11e 2 —7 Q 7
ififomlatlon s � 6501 Wilmett.Road
re.ery P4 9- Bethesda MA 20817
every:page. City/Town � , .A, Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
0/
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t5IMP.doc•0=6 Me 5 Official Irspection Foam:Subsurface Sewage Disposal System•Page 14 of 15
7
Commonwealth:of Massachusetts
.� Tithe 5 Official Inspection Form
Subsurface Sewage Qisposal System Form-Not for Voluntary Assessments
159 Sea View Ave.,._Osterv_ille
Propel"ddress. APN 162-020
.Owner" Owner'srtame ;Bryon & Heather Corsini *'
informawnis 6501 Wilmett Road 0,
required for Z d
every page. Cityrrown Bethesda, MA 20817 zip code Date of iris n
D. System Information (coot.)
Site Exam:
9-Crheck Slope
Surtace water de'c-evL 4W
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:.
❑ Obtained from system design plans on record
1f checked,date of design plan reviewed: Date
❑ Observed site(abutting propertylobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
dbpi%s► :,, lea c ► 6)2410.1
❑ Checked with local excavators, installers-(attach documentation)
❑� Accessed USGS database-explain:
You must describe how you establishle�d the high ground water elevation:
is
SG -F,'rr• � J� 2�- `ZC9�-� c�.2.vvtc�t s ��
^(�-►��e �G� �1 �-�w-e�-v. b�fir^ C e s S�oa l 5�vr�,,�x-1-e
t5fr"A c•OW6 Title 6 Offidal Irapectlon Form:Subwftce Sewage Disposal System•Page 15 of 15
. r
Town of Barnstable
�F tHE Tp�
Regulatory Services
�xxsTns Thomas F. Geiler,Director
MASS
9� 1659. ��� Public Health .Division
pTED MA'S A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic.
System Inspector who conducted the inspection.
P '
' ^ J
L\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 150 Seaview Avenue
y Osterville, MA 02655 t/Yn
Owner's Name: Barry&Julie Jaye ASSESSORSMAPMo.
r
Owner's Address:
ppRCp,NO•,.._
Date of Inspection: June 25, 2004
Name of Inspector: (Please Print)James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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 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
Needs Further Evaluation by the Local Approving,Authority
Fails
Inspector's Signature: Date: June 28, 2004
The system inspector shall subm• 4copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
4
Page 2 of I 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
NID explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health): ,
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system,will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
i
Page 3 of 11
OFFICIAL INSPECTION-FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
i
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
_ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
✓ ]Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 150 Seaview Avenue
Osterville, W
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J.
5
I
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents: 2
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310"CMR 15.203): end
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
✓ Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown-orikinal
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 1 l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM INFORMATION (continued)
Property Address: 150 Seaview Avenue
Osterville:MA
Owner: Barry and Julie Jaye
Date of Inspection: June.25, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank)
Depth below grade: Cover to eade
Material of construction: concrete _metal _fiberglass _polyethylene
✓ other(explain) Brick
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
i
Dimensions: 6'W x 8'.T x J 0'bottom to grade
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: J"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Measurinu stick
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 cesspool had 5'of water on the bottom. An outlet tee was present The cover was to Qrade
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
SOIL ABSORPTION SYSTEM(SAS):, ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The overflow cesspool was 6'W x 7'T x 9'bottom to grade and was dry. The overflow cesspool was brick. There did not
appear to be any signs offailure. The steel cover was to grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
PoL Ll
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10
Page 11 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 150 Seaview Avenue
Osterville, MA
Owner: Barry and Julie Jaye
Date of Inspection: June 25, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
✓ 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:
l hand angered down to 13'below grade and no water was observed. Using the Cape Cod Commission technical bulletin, the
high ground water adjustment for this site(MIW 29, Zone A, 5104)was 1.5'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed, written or implied, relating to the system, the inspection andlor this report.
y - -
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ARCH I'FEC TU R AL DESIGN
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B WEST BAY ROAD OSTERVILLE.AA 02955
k I I NOTES:
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Front Elevation
5GALE: 1/4" = V-O" d
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I
1 - '
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Left Elevation Right Elevation I LLi
5GALE:1/4" _ CID
1'-O" 5GALE: 1/4 = 1'—OII > o
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BACK YARD PROJECT 2.0
Rear Elevation i I -
I 5GALE: 1/4" = 1 O;'
- SET ISSUE OATES
. + • �... n • DATE ISSUE
f II Ir ! ASPHALT SHMGL.E5 _
�1 721 OVER FULL I
COVERAGE ICE 4
AZEK WRAPPm A2FJc 1 —WATER SHIELD I RBnSIONS
F'42.APPEp(2)1-3/4-x11'1/b'VPRSA- {
VERSA.LAM BM —y '1 �M B�_—O.G I - 0 DATE DESCRIPTION
' SIMP50N PGBZ • — SIMP50N H2.5 -
' - POSTGAP (9 2x10 HDR— _� CONNECTOR®TOP
FASTENED TO PLATE 4 RAFTER TYP.
EXISTING PORGN 2X6 STUD WALL
. ( BE4MI 18'-0" . I 1/2"GDX PLYWOOD 5HEATHING
W.G.5HINGLES ABOVE STONE VENEER _ -
P X4 POST D W - f -
i 5/5"ANCHOR BOLTS
I•. 10�COL. EMBEDDED I"
I ED 32"O.G.
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- 51M�N �. '.' WASHERS 3"x3"x1/4" -
1 OFF,BASE STAND-
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ITE BOLT N
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CONCRETE PIER F Ya a�x rn�v+"" �' '�{t 'I'1 �#' �•M �,}T t �3 �xA'�`iS a I�`#`°"'1�t
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SHEET 10F2
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5GALE: 1/4" - 1,_O❑
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t I- ,. ,sue. '±u o- .., ,..... 1 I_ t. ,.:: .. a. -.:.. ,5.: w ..:ah�:i ,e.#�.?"'�^ '��§.X a.r.,,_,.,i.•r, .:.tip^ r.
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ARCWTECTURAL DESIGN`
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A - P 508d20-1296 cYl
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8 WEST SAY ROAD,OSTERVILLE MA 02666
`. • y NOTES
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