Loading...
HomeMy WebLinkAbout0800 SEA VIEW AVENUE - Health 800 Sea View Avenue `rye�nle A= 114-069 I k� 0 'i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftPlitation for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No. 200 56A V IO'd AV E Owner's Name,Address,and el.No. St�4(/1 Rob N( O—OR5091 Assessor'sMap/Parcel 90O SeA view Aus dsTEkV(LCC- Installer's Name,Address,and Tel.No.J Og—t-i'l $ `t Designer's Name,Address,and Tel.No. CA r�tD� 9J�� M NIA Type of Building: Dwelling No.of Bedrooms Lot Size a.•�� �. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank - Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) PIC—?L44CIC— BOX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issue his Board of Health. ig d NjIf Date '� b l 3 Application Approved by Date Application Disapproved y Date for the following reasons Permit No. , Date Issued 61 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ..., PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(V- Upgrade( ) Abandon( ) El Complete System XIndividual Components Location Address or Lot No. 200 SE-s4 V f CMJ AV E Owner's Name,Address,and el.No. STatt/f ROb PF- L'O'RS0N Assessor'sMap/Parcel + � E Imo) AUG OSZj . (4,41 Installer's Name,Address,and Te.No.50 tj-1 Designer's Name,Address,and Tel.No. C.4oc�tD� ��tPa,s fir`' s�fo NIA Type of Building: - Dwelling No.ofBedrooms Lot Size �L Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date r�—� Number of sheets Revision Date Title O Size of Septic-Tank Type of S.A.S. Description of Soil /y Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issue this Board of Health. ` i ed / e Date -5 ©l 3 Application Approved by Date Application Disapproved by r Date for the following reasons Permit No. Date Issued -------------------------- ----- --. :. _. -- _-_ - _ -----------------------------------------------==-- -` TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS _. f Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by CAPC—wjp EQT RPt?(s6S [4r— at e _-r,_(=. U( =00,<�T U f U ; has been const PCted• acc with the provisions of Title 5 and the for Disposal System Construction Permit No. d Installer (1406tvl-PG EPIWO L�J&S Cl—C. Designer N�/4 #bedrooms Approved designflow gpd w; The issuance of this permit shall notj�bec�o)ns rued has a gyarantee that the system willl • �ctioofi_as fdesi//g/ned/� Date �/ f Y l! C Inspector f (9 l't/d�( Yi'� 1 („,rf I i�l►+ No. �/U/j Fee . t� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( X Upgrade( ) Abandon( ) System located at '2dy se& L/ r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru io . use completed within three years of the date of this permit. Date Approved by IMaY 04 2017 22:16 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IN 800 Sea View Ave. ... Property Address T Rodney Corson Owner Owners Name / w information is required for every Osterville V MA 02655 5-4-17 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 ��Z 9� �p�tunt►nfp� on the computer, �0! �{OF 'y�i, use only the tab 1. Inspector: �:#` • �� • s; ��'% key to move your a ?.' S cursor-do not James D.Sears _ JAMES ,use = key the return Name of Inspector ;y 3 Capewide Enterprises =*' e Company Name .� -'�RT11e I 153 Commercial Street �!'F 5 INSpEG���``\ Company Address yea Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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. aspectors � - 5-4-17 Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. l5ins.doc-rev.6116 Tille 5 Official Inspeclon Form:Subsurface Sewage Disposal System•Page 1 of 17 D?)Z-d V Max 04 2017 22:16 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F` 800 Sea View Ave. Property Address Rodney Corson owner Owner's Name information is required for every Osterville MA 02655 5-4-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and two pits. 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.doc•rev.6116 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Max 04 2017 22:16 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 5-4-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑.N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water, ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ISina.doc•.ay.8116 TiUs 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 May 04 2017 22:16 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 5-4-17 page. Cityrrown State Zip Code Dale 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 1111NO1111111111 is less than 6" below invert or available volume is less than '/day flow ,p;Ts t5ina.dac•rev 6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 4 of 17 May 04 2017 22:16 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts t Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson owner Owners Name information Is required for every Osterville MA 02655 5-4-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (corn.) 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 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 11 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. i5ins.doc-rev.W16 Title 5 Official Inspection rorm:Subsurface Sewage Disposal System-Page Sot 17 Y May 04 2017 22:16 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owners Name information is OSteNllle required for every MA 02655 5-4-17 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: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official hspection Form:Subsurface Sewage Disposal System Pege 6 o(1T May 04 2017 22:16 Jim The Inspector Man 5085349919 page 7 W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 800 Sea View Ave'. Property Address Rodney Corson Owner Owners Name information is OSterville required for every MA 02655 5-4-17 page. City/Town State Zip Code Date of Inspedlon D. System Information Description: The system is a 1500 Gal. Tank D Box and two pits Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No II Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011-169,000Gal Detail: 2012-198,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA 0 ate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersonslsq.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: Wns.doc-rev.B176 Title 5 Official Inspaction Form:Su6eurfeoe Sewage Disposal System•page 7 of 17 Max 04 2017 22:17 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 5-4-17 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: 10-23-07 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): t5tns.doc-rev.6116 Title 5 D 681 Inspection Form:Subsurrace Sewage Disposal System-Page a of 17 May 04 2017 22:17 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owners Name information is required for every Osterville MA 02655 5-4-17 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1982 Permit #82 -327/ 12 -2013 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 301,feet Material of construction: ❑ cast iron ® 40 PVC ❑other(explain): Distance from private wafer supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 20"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: 1500 Gal. Precast H-10 Sludge depth: 1" t5ina.doc•rev.6/16 Title 5 Of fat Inspection Form:Subsurface Sewage Disposed System•Page 9 of 17 i May 04 2017 22:17 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 5-4-17 page. City/Town State Zip Code Date of Inspection D. System Information (cons) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness Oil Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and outlet cover at 20" below grade w/inlet cover at 4". In and out let tee's.No sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal 0 fiberglass ❑ polyethylene y ❑ 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 *ns.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 May 04 20101 22:18 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Name information�s required for every OSteryille �eve MA 02655 5-4-17 page. cityrrown 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 15hs.doc-rev.6r16 Tille 5 Official lnsDect on Form:Subsurface Sewage Disposal system-paw 11 of 17 I i f May 04 2017 22:18 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 Sea View Ave, Property Address Rodney Corson Owner Owners Name information ti is required for every Osterville MA 02655 5-4-17 page. CityrTown State Zip Code Date of Inspection D. System Information (cons) 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.): D Box is new 12-2013. D Box is 16"x16"-2' Below grade w/cover at 6" Two lines out Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: 15ins.doc-rev.6118 Title 5Officlal Inspection Fort:Subsurface Sewage Disposal System-Page 12 of 17 May 04 2017 22:18 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Narne information is required for every Osteryille MA 02655 5-4-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ ,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.): Leaching is two 1000 Gal, precast pits w/2'stone. Pits are 30"below grade. Pits are dry. No sign of over loading or solid carry over. Stain line at 30". i 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 15ins.cloc•rev.SMS Title 5 Official krspeoion Form:Subsuifete Sewage Disposal System•Page 13 of 17 May 04 2017 22:19 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Crooner Owners Name - required for every Osterville MA 02655 5-4-17 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.): 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.): t5ins.doc rev.6/16 Title 5 Official hspectlon Form:suosur"ce sewage Oisposel Syatem•Page 14 of 17 May 04 2017 22:19 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 5-4-17 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Cf 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 Will( AIL 3 A- � 13...-r���� 3 t s -�= r •t 0 0 ,A-3= 6-3= 35 - :_5Y t5ins.doc-rev.6115 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 May 04 2017 22:19 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 800 Sea View Ave. Property Address Rodney Corson Owner Owners Name information is required for every Osterville MA 02655 5-4-17 page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar n ❑ Shallow wells N� Estimated depth t high ground water: 13'+ 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: 6-28-79 Date ❑ Observed site (abutting propertylobservat ion 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: T.H. on design plan 6-28-79 13' no G.W.. Bottom of pit's at 8'-6" below grade. Bottom of pit's at 4'-6"above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6118 Title 5 Official Insaaction Form:Subsurface Sewage Disposal System•Pape 16 of 17 May 04 2017 2220 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 800 Sea View Ave. Property Address Rodney Corson Owner Owners Name information is required for every Osterville MA 02655 5-4-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins.doc•rev.6/16 Title 5 official Irwpedlon Form:Subsurface Sewage Disposal System•Page 17 of 17 00Q ec 12 13 08:33a p.1 ■ ■ ■�M Commonwealth of Massachusetts ■ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02656 12-11-13 page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information `��l�uunmlrrrpi on the computer, ``�������•(N OF Mqs use only the tab 1. Inspector: key to move your cursor-do not JAMES James D.Sears =�: use the return k . Name of Inspector :cn ey CapewideEnterprises,LLC o '0 Company Name ���,; ?TT •���� 153 Commercial St. /����''�uui ruruP►�G���``` Company Address Mashpee MA 02649. CitylTown State Zlp Code 508-477-8877 S1623 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 _ 12-11-13 ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the 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-'3113 TAW 5 Officpbspecdfion Form:Subsurface S swage Disposal System•Page 1 of 17 Dec 12 13 08:33a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 12-11-13 page. City/Town State Zip Code Date of Inspection B. Certification (coat.) 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 Heath, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below)_ t5ins•3113 Titla 5 ORcial Inspection Farm:Subsurleoe Sewage Disposal System•Page 2 of 17 I Dec 12 13 08:33a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form k w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is Ostervllle MA 02655 12-11-13 required for every page_ City/Town State Zip Code. Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ` B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 151ns-3113 Title 5 04Tdal Inspection farm:Subsurface S"a Disposal System-Page 3 or 17 Dec 12 13 08:34a p.4 Commonwealth of Massachusetts MUMM Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 12-11-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health.(and Public Water Supplier, if any) kv 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 is less than 6" below invert or available volume is less than %2 day flow PITS 15ins•2113 Title 5 Offiaal inspection Form:Subsurboe Sewage Disposal System-Page 4 of 17 Dec 12 13 08:34a p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owners Name information is required for every Osterville MA 02655 12-11-13 page. Cityfrown 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 10.0 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 flaw 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 Beet 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, y 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 15ins•3113 We 5 Official lnspectlar Form:Subsurface Sewage Disposal System-Page 5 of 17 'Dec 12 13 08:34a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner owner's Name information is required for every Qsterville MA 02655 12-11-13 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ N Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 !Sins•3I13 Tiede 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 6 of 17 Dec 12 13 08:35a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form k J1 Subsurface Sewage Disposal System Forth- Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every psterville MA 02655 12-11-13 page_ Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank, D Box and two pits. 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) m Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)):' 2011-169,000Gal 2012-198,000Gai s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialfindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersonslsq.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 3n3 - _ Title 5 Otfidal Inspection Form:5t6axfaoe Sewage Disposal Syst®n-Page 7 of 17 Dec 12 13 08:35a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is psterville MA 02655 12-11-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cone.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: 10-23-07 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): Mrts•all Title 6 Official tnspecficn Form Subsurfw:e Sewage Disposal System•Page a of 17 'Dec 12 13 08:35a p.9 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 800 SeaView Ave. Property Address - Rodney Corson Owner Owner's Name. information is required for every Osteryille MA 02655 12-11-13 page. City/Town State Zip Code Date of Inspection D. System Information`(cont.) Approximate age of all components, date installed(if known)and source of information: 1982 Permit # 82 -327 1 12-2013 New D Box. Were sewage odors detected when arriving at the site? 0; Yes '® No Building Sewer(locate on site plan): y Depth below grade: 30„ feet Material of construction: ❑cast iron ED 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet • i _ - Comments(on condition of joints, venting,evidence.of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): , 20 Depth below grade: feet Material of construction- ER concrete ❑metal fiberglass © polyethylene ❑ other(explain) If.tank is metal`' g e:list a years . Is age confirmed by a,Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑, No Dimensions:. 1500 Gal.Precast _ 3" Sludge depth: t5ins .3113 Title 5 Oftiel Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17. 1. e. r Dec 12 13 08:36a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 12-11-13 page. Cityfrown stater Zip Code Date of Inspection I D. System information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 27" 2rr Scum thickness 8„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to'bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and outlet cover at 20" below grade wlinlet cover at 4". In and out let tee's. No sign of leakage or over loading. Grease Trap (locate on site plan):. Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: r 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 Mrs-3113 Me 5 official Inspectlon Form:Subsurfte Sewage Disposal System-Page 10 0117 Dec 12 13 08:36a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson �'^ef Owner's Name information is Osterville MA 02655 12-11-13 required far every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, Well 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: ` Dace Comments(condition of alarm and float switches,etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3113 Title 5 Official Inspection Form:SubsWace Sewage Disposal System•Page I of 17 Dec 12 13 08:36a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owners Name information is required for every Osterville MA 02655 12-11-13 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 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.): D Box is new 12-2013. D Box is 16"x16-2'. Below grade w/cover at 6". Two lines out. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order ❑ Yes ❑ No+ Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: . 4 t5ins,3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Dec 12 13 08:37a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 12-11-13 ' page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number. 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool 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.): Leaching is two 1000 Gal. precast pits w/2' stone. Pits are 30"below grade. Pits are dry.. No sign of over loading or solid carry over. Stain line at 30 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 Isms 3113 Title S Official lnapection Forth;Subsurface sewage Disposal System-Page 13 of 17 .Dec 12 13 08:37a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name inforrnat• on is required lfor aY Osterville MA 02655 12-11-13 cityrrown page. Slate 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.): 15ins.-3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 14 of 17 Dec 12 13 08:38a - p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 12-11-13 • page: City/rows State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks- Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 2 Gj 14 - � = �s 0 t5ins-3113 Thk 5 Official Irmpeaon Farm:subsrorace Sewage Disposal System-Pegs 15 of 17 f Dec 12 13 08:38a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name informationis requiredairedfor every Osterv8le MA 02655 12-11-13 for page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nv Estimated depth tohigh ground water. 1 feeett 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: 6-28-79 Date ❑ Observed site(abutting propertylobservation 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 groundV water elevation: T.H. on design plan 6-28-79 13' no G.K. Bottom of pits at 87-6"below grade. Bottom of pit's at 4'- 6" above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Of9dat Inspection Form Subwrtam Sewage Disposal System-Page 16 of 17 Dec 12 13 08:38a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 800 SeaView Ave. Property Address Rodney Corson Owner Owner's Name information is required for every Osterville MA 02655 12-11-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information=Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r5ins.•sn 3 Title 5 Offidal Inspection Form:Subsurfew Sewage Oispwel System•Page 17 of 17 - 900 LO,CATI N SEWAGE : PERMIT N.O. VILLAGU/2 �. INSTA 'LER'S NA & ADDRESS BUILD R OR OWNER DATE P E.RMIT ISSU E .D DATE C0MPL UANCE ISSUED = � � j ---------------------- ?UN. 21. 2004(TUE) 14:41 CENTERVILLE FIRE 5087902365 PAGE- 2 1-2— appiacaxiort to loca1 vice uepartrnent. Fite Department retains original,application and issues duplicate as Permit, ¢mom, .., •'VG!/iF,���//Y/I�LE�]LG O�i�L��/�tJ(�• •✓GISIT+�l./JL� v/F�� R`': APPLICATION and for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, applicatiory is hereby made by, a Tank Owrter Name(please.print) Rodney' Corson Address - n 6rraal n r ° pill Gut Sleie trp Company Name Env i ro—Sate- enrpoxa t i on Co.or Individual n aJ Address 148� Jan29bastian 1�riwr SM"d1w:ictir. N.0256 !, p,�t Prim — Acfdresae,I JS� .A ¢+j, - Signature fif applying for permit) 2 ' ` Signature(if abo-tying for permit) ❑ IFCI*Certified Other ® IFCt"CertiPled �- — . ❑'LSP#�_ other y�� Tank Location 600 Seavi(�w 'Avenue`, 08trervi`11e,` ptA �. Yank Capacity(gallons) ` 100 Substance last Stored #2 of 1 Tank Dimensions(diameter x length) Remark" p .... . Firm transporting waste �'e State Lic. Hazardous waste manliest# .91 M:�M 815 7 3 0 i*aP°A,# " 52098l3 t Approved tank disposal yard Ind G`�ty - 128$9 Tank yard 9 `type of inert gas Tank yard address W State R I, westv=tf M F i . . conservatio:a, Dept.. : GitV br Town - ry Dat e `� FCIYD# _Q],Qg Permit# Dale of issue s ----�--- 7 Date of expiration July 5, 2004 oig safe approval number: _2 4-24p1986 Di — -- — -- fe o Free T , N • - "� T ber=800-322m4844 , Signature J Title of Officer granting permit After remavai s ( ) ("Ccnsumptive use,fuel oil tanks exempted)send Form FP•29OR signed Y Local Fire Department to Cftice of the State Fire Marshal, US7 Regufstary Compliance Unit, P.O. Box 1025, Stow,MA 01775. 'International Fire Code institute '•292(rHbised 41971 LOCATION EWAGE PERMIT NO. VILLAGE Ilk INSTALLER'S NM & ADDRESS d2z,� O�*14, ee- ice. 7&vai?�;"- wl OR OWN ER c � ' DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� f1 �/,ceiw r� NO.- FEB......... ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® ..OF HEALTH ...................... . -----.........OF...........................--•-- �� ApplirFatinn for Dispati al Works (Sumitrurtilan Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at. .. .. 4C`' �lif�� ��� ------ ..... ....................................................... L��^� •-- y Locati n-Address or Lot No. .11.�...................................... ..... .� ------- W �) Y p Owner l "' !�.c_.. •. �re s.... ......•--- ••• a - Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria . p' Other fixtures ....................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity._..._.._...gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY................................................--------- •----•----------- Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ -•-------------------------------------------------•-----••-•---•--.......................--•.••••--......................................................... 0 Description of Soil........................................................................................................................................................................ x V ----------------------------------- •-•......-------- •------------------------------------------------------------------------------- -----------------------------------------------•---------------•---- -----•----------•-------------------•-----------......-----------------------...-------------------------------•----------------....-- U Nature of Repairs or teratio —Answer when applicable.___' ' .... ........................... .... P..I.^9/!':.-. ..'. ............................................... .................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d by t e board of h lth. Signed- ...••. ... .......................... - ----------------- ..--- Date ApplicationApproved BY.................................................................................................. ......................................... Date Application Disapproved for the following`reasons-.............................................................................................................. ----------•---•.....................•-------------------------------------------.......•••-••----------•--•-•--••-•-•---••-•----•-•---•-•-----•-•--•-•-----•••--•-•-•---•-•--•--•--- Date PermitNo......................................................... Issued-....................................................... Date Fmc.........No. — — = =--� T� ........ THE COMMONWEALTH OF MASSACHU.SETTS BOAR® OF HEALTH ........................... ...........OF..........................._..........-------------...---.....................:........ Appliratiun for UWpaial Workg Tunudrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• , t .: . ' .... ............. ------._...._---••-........_----• -- •--......._........_.._............... Locati Address or Lot No. .. .. ....... ........ ...W.. ..........._..........................•.... ..................l....G....---�•••......•-•-.. e •a ... ......_.. ner ddre ... ...... -1 a ........................ � •- Inst Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) �+ Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --------------------•__--_.-.--__. W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ GX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P1 --------•--------------------.................:............................................................................................................ 0 Description of Soil......................................................................................................................................................................... x V ----------------------------- ------------------------------------ •.................... ----------•---•--------•-••-•------•--••-------•------•------------•••-•---.......... ••--•--- W -------- ---------------------------- ............ U Nature of Repairs or A eratio Answer when applicable...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provis"ons of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is�ueAl by t e boa d of ie lth. Signed - . - ' �. .. r ...._......-•••......... ..... ..._ ..._._... Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons:••------•-----••---------•-•-----•--•--...------•---••--•--------•----•------•------••-•-----•-•--•--------•••-- -••-••---•-•---•-----•--•-•-••••-•-•.................•-•---....---..._..__•-•-----••-•-•-----•••••••••----•--•........•-•--••----••--•------------•---------------------------------••---- •------------ Date PermitNo.......................................................... Issued-------------------••-------.......------------------. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................."I.........OF..................................................................................... (Irrtifiratr of TwIlutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY-•-------•--•--•----•-•-•---•----------------------a:.`.......1_44,zt�..-----• ••-------............--•-•-•------............................................................... e Insta at----••------------•------•-----�-���.........e-4*....... .cRn-�-------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......� '. ` ......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................. .� `�(:g`'...._....- Inspector....--------.---- - -1- .6........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF................................-.................................................... .. . No.... FEE.... ............. I Utoposal Workn 0L.11mitrur#ivn "Van fit Permission is hereby granted..............A-----=' `` .......--------•-------------•-------------------------..._......-------•--...................... to Construct,;. ) or Repair ("an_Individual Sewage Di al System atNo. ................ ..,. .. '.!�.�.........-•---•......�4 ....---------------.....------•-----------------------------------------.......---•-•-- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Board of Health- DATE............................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i Ll LO CAT 1 aSEWAGE PERT' I�0• �� � IN MIo V I C L A G E INSTA L,LER'S M/A E & ADDRESS C-B� � �� ✓cam- �� oft , OWN ER. DATE PERMIT ISSUED '— DATE C0MPLIAPICE ISSUED Liri ` s h 0 0 �z 6�-:,O / � i.,/'l LeCATI N �, / r SEIldAGE PERMIT NO. { VILLAGE/? INSTALLER'S NA Q ADDRESS a 0 U I L D R DR DINNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1 � > FE11 �3d............... No......... ............ THE COMMONWEALTH OF MASSAC14USETTS BOARD OF., HEALTH 4& ...............tl�_�_ -----------OF.............. ............................................ Appliration for Dispatial Workfi Towitrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Systemat:............ i�- -- ----------------- ------------------------------- ............ ...................... ........... Location-Address or.. 'P No. 44--7.A.-tr-,e.... ................. ... ............. -------n.e r Address .... .... ........................................... ................................... ............................................ Installer Address USize Type of Building Lot ......Sq. feet Dwelling—No. of Bedrooms.........3................................Expansion Attic Garbage Grinder (L-T� ;j Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures .................................................................................................. Design Flow...........ao.,.......................gallons per person per day. Total daily flow__.._. 9 Septic Tank—Liquid capacity15)!7.V..gallons Length................ Width................ Diameter..._............ Depth................ Disposal Trench—No...................... Width........ ....._.... Total Length ... Total leaching area sq. f t. Seepage Pit No...1................ Diamet Depth below inlet..: ........... Total leaching area- ..SZ1. ft. z Other Distribution box Dosing to h Percolation Test Results Performed by....... ......... .................... .. ......... Date...6 Depth to ground water..,&-mv............ Test Pit No. I...in........minutes per inch Depth of /test Pit............. ....7el Test Pit No. 2................minutes per inch Depth of Test Pit.._............._... Depth to ground water......_............._... ---------------- ------------------ -----------------------------------­*---------------------------*...... - -------... ............................. 0 � .1 Descw -ription of Soi... ..... .1... ..... --------------------------------------------------------------------------------------------------------------------- ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLILT,LE 5 of the State Sanitary ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bW issued by the board of health. Agned. . ... ................... ................... ... /----------- Date Application Approved By... ....... . ...... .......... ........... - ------------- ....... Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo........................................................ Issued..................................................... Date ,OF� -;T1. Id No...................... FEE.....`.. .!...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 2HEALTH ....OF..............k:�e:24' ............. ---- ... ............................................. Appliration for Disposal Works Tonstrurtion rumit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: I At . ....................... 7 ........................... A I.ocation-AdIress gto or/Lo 4,_ ....40..f-_-b�_ . ......................... .......... ................................ .................... ........... ......... ..... ner ... ...... ............................ Installer- ....... --------- -----------­ .......­........ S----U Type of Building Size ...... q. feet Dwelling—No. of Bedrooms......... ................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ..............................................................................I............ Design Flow...........KfO..........................gallons per person per day. Total daily flow---- ....._....gallons.-"-' 1:4 Septic Tank—Liquid*capacity/5-Y-T..Lyallons Length................ Width...._........... Diameter...____......... Depth................ Disposal Trench—No..................... Width... Total Length.._...... ......... Total leaching area..._.._. sq. f t. -I beloW)nlet.... Total leaching area i.................S4. ft. ------ ......Seepage Pit No...1................ DiameteFi_ .A'_Deptl ---------- "bosin,g tank X Z Other Distribution box 121 - . 7�1 _ Date...t1. ................................ Percolation Test Results Performed by.......... -i Test Pit No. I...:?��........minutesperinch Depth of Test Pit...._... ..:. Depth to ground water...6'L ---C......... f� Test Pit No. 2................minutes per inch Depth of Test Pit..____.........._... Depth to ground water........._...._......... P4 ........................ .......................................... 0 Description of Soil.....671 .......... ........... . V ry .... .................................................................... ............................................... U 7 :IV ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ....................... ................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'L, - 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has, 1 -4n issued by the board of health. greed ............ 4 .......... ..........�: ........................... ............... ....... i Date Application Approved By--- .......... Date Application Disapproved for the following reasons:.............................................................................................................. ....................................... .......................................i............................................................................. ..................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT�# .............. OF............ .. ............... (9rdifiratr of Toutpliattv 'T,T,2_- CERIti'v em c ns T I TO Y That th I' d;vidual Sewage isVposal y st t,V&,t4te�d'Mrs S 11 - / �� or Repaired 4 r:� . 4j - by...... .......... ..... Ak ............................ Vci )l In taller at..... ---------- . ............. .... .. ................ *--------------------------------------has been instilled in accordance with the provisions of T of lie, State Sanitary Code as d ibed in the 9' ........................... application for Disposal Works Construction Permit No- -------- .... .....17..... dated------- VD, ..... .... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM'WILI: FUNCTION SATISFACTORY. I DATE................ Inspector-6".. . ..a,... ------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH..... .... .. ......OF.............pZ.a-_k1-f.1 .. . ............. .......1,7 N ......... FEE......................... ;OOT Permission is hereby granted........;Trf........ ........ . .... ........................................................... to Constr or Rep r) an Individual ewageDis osal Syst atNo... _1�j.... ..... ................................. .......... Street -, , I I ., f___1 J as shown on the appli tion for Disposal .Works Construction Permit No.................... Dated.......................................... . ........................................................................................................ fZ A Board of Health DATE_ --------------------- ---------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS hk ' 1 r>Att��f t=•Low � Ito � 3 rG�05�Q�G.P.R u l:>tSPoSAL axve" /2`yio►,#� 6oTT0A.. Arct/a = 47a 6 7, -`s f ToT L C7E51Gh1 �X(�S b PEF-cO"T tot,1 P-A Tr= l 'i u 2 AW.I oQ L2.6. 2:15 'TEST ' 4 • —,Op Fa.ry = bo' �� , , ., i ii• .,. •� vi�wii C t_t q 9 7,� 4' fi ''PPE luu • Q� LodW ¢ (Soo w A v. ; y 4"'wt D15T tuv SvgSolt. Box. �L L SF�PfIG 2 11N. TD U 14 96•0 1 uv. luv. r��rc SAu� t.FAct-1 .0 3' QI T WAW9D STO W - r � C E2 T t F t E D GI._OT' pt_A *.-s I.�o Vt./aT z Pzo pose.rl-� t CCMTIF�( T"AT Tk1E. `Dw�s.LL.tiJGa SNowu "Eq-E.o►4 GOMPL-Y S W t'rH T"e- ZstDELl h1E L,,T- -LU-� Aub SETt3,acK R6c?u1Zf--MEUTS OF TWE. Tbt�/a1 c F- iB 4(zt�e7 A. �ov+zT 2G�O� - 1 n.L, SZ.�.tsrE rZ� t_aa�n yt,�2vE�{oe� T4415 PLa" 14 1JOT $a5E'D o1J AU iQ4TWMEuT AAJLCYS• 5UQ%./Mi 4 TNc 0FF5Er; e7"OULt> UOT ;5E U',E.C> APPLtC A. .Xr t r � t Fill •` 2G• to \ r.�wit 1 \� ?Coo oo 1 a