HomeMy WebLinkAbout0051 SEAPUIT ROAD - Health 51 SEAPUIT ROAD
OSTERVILLE
/ A= 118 - 124 -003 ,
TOWN OF BARNSTABLE
LOCATION/ ��a(1�f� r A.5 v SEWAGE # y
VILLAGE ry`le ASSESSOR'S MAP & LOT ,,�
INSTALLER'S NAME&PHONE NO. �
SEPTIC TANK CAPACITY
LEACHING FACII.TTY: (type) (size)
NO.OF BEDROOMS
BUII. OR OWNER,. eas-
PERMTTDATE: oZ " f�-e/$ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland,and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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A 61�
Aug 01 2018 16:35 HP Fax page 37
l!g- /,Zyf 6 03
,K11\ Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Ford Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °'
r fi A
' 51 Seapuit Road ;1
Property Address '
Alyson Wygonski
Owner Owner's Name ,',
Information is required for every Osteryille MA 02855 7-30-18
1�
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 and of the form.
�g11I1 ltl4r/!rj
Im rtant:When J!
�° A. Inspector Information o� ;
tilling out forms /302 � ••.P�'�
on the computer, �� ., JAMES G
use only the tab James D Sears =4
key to move your Name of Inspector =v; SEARS y
cursor-do not Capewide Enterprises
use the return Company Name RT10 •' O
key. 153 Commercial Street 9,, iFS
QV Company Address h e1HuuplNw�"�
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
UPV?'L,,�,. 7-31-18
ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of Inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2 6120 1 8 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
.�U ICU f
Aug 01 2018 16:36 HP Fax page 38
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Seapuit Road
Property Address
Alyson Wygonski ---
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every
page. City(Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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 H-20 1500 Gal Tank D Box and Field.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be:
replaced or repaired. The system, upon completion of the replacement or repair,;as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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Aug 01 2018 16:36 HP Fax page 39
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
<ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Sea uit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every State Zip Code Date of Inspection
page. City/rown
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
15insp.doc-rev,7126MI8 Title 6 official Inspection Form:Subsurface Sewape Disposal System-Page 3 of 16
Aug 01, 2018 16:37 HP Fax page 40
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f
51 Seapuit Road
Property Address
Alyson Wygonski —
Owner Owner's Name
information is required for every Osterville MA 02655 7-30-18
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fall 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 its within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a se
ptic tic tank and SAS and the SAS is within a Zone 1 of a public water
❑ p
Y
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is;equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis:must
be attached to this form.
c. Other
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/2e12016 Tifie 5 Official Inspevion Form:Subaurfece Sewage Disposal System-Page 4 of 18
,Aug 01, 2018 16,37 HP Fax page 41
Commonwealth of Massachusetts
Titles Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�
1� 51 Sea uit Road
Property Address
AI son Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in NORM is less than 6° below invert or available volume is less
than '/2 day flow J-M t IA4
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis.,[This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal colifonn bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
El ®. The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 16.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El 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
t5in3F.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-page 5 of 18
Aug 01 2018 16:38 HP Fax page 42
,t\, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Seapuit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
11 ® this inspection?
® ❑ 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:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
t5insp.doc•rev.7/26/2016 Tlt:e 5 Official Inspection Form:Subsuface Sewage Dispose I System•Page 6 of 18
Aug 01 2018 16:38 HP Fax page 43
c Commonwealth of Massachusetts
r Title 5 Official Inspection Form
krAl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Seapuit Road
`�✓ Property Address
Alyson Wygonski
Owner Owner's Name
Information is required for every Osterville MA 02655 7-30-1 S
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
: 4actual
Number of bedrooms(design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 16.203 (for example: 110 gpd x#of bedrooms): 440
Description:
H -20 1500 Gal. Tank D Box and Field.
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonaluse? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)): 2016-280,000Ga1
2017-193,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
t5insp.doc-rev.7/2612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 1S
Aug 01. 2018 16:39 HP Fax page 44
Commonwealth of Massachusetts
p Title 5 official Inspection Form
subsurface Sewage Disposal System Form-Not for Voluntary Assessments
< 51 Sea uit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is required for every OStervllle MA D2655 7-30-18
page City/Town State Zip Code Date of Inspection
D. System Information (cost.)
2. Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancyluse: Dace
Other(describe below):
3. Pumping Records:
NA
.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:
t5'in sp.doe-rev.7/281201a Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 18
Aug 01 2018 16:39 HP Fax page 45
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal!System Form-Not for Voluntary Assessments
!y 51 Seapuit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is required for every Osteryille MA 02655 7-30-18
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ lnnovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1996 Permit # 96-6621 7-2018 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
22"
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.);
Pipeing is 4" PVC SCH-40
,I
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Aug 01 2018 16:40 HP Fax page 46
Commonwealth of Massachusetts
paoww Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Seapuit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is required for every OSterville MA 02655 7-30-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H-20
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle'
27"
2"
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 1' below grade wlsteel cover on inlet at 8" below
grade In and outlet tee's No sign of leakage or over loading. Note: Maint pump afther inspection.
l5insp.dac-rev.7126=18 Title 5 0fliiclal Inspection form:Subsurface Sewage Disposal System-POP 10 of 1b
Aug 01 ,2018 16:40 HP Fax page 47
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;P
r 51 Sea uit Road
Property Address
Alyson Wy onski
Owner Owner's Name
information is Osteryille MA 02655 7-30-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Traplocate on site plan):
( p )
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.WM201a TOO 5 Oflidal Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Aug 01 2018 16:40 HP Fax page 48
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Sea uit Road
Property Address
AI son Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every
page Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
'Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
0
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H 20 D Box is 2'x20" -2' below grade w/two line's out Box is new 7-2018 wlcover at 6".
15insp.dac•rev.726=18 Title 5 Official Inspection Farm:Subsurface Savage Disposal System•Page 12 of 10
Aug 01 2018 16:40 HP Fax page 49
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not For Voluntary Assessments
,. 51 Sea uit Road
Property Address
Alyson Wygonski
Owner Owners Name
information is required for every Osterville MA 02555 7-30-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass,
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
if SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number.
❑ leaching trenches number, length:
® leaching fields number, dimensions:
12'x50'
❑ overflow cesspool number:
❑ innovativelaltemative system
Type/name of technology:
tSinep.doc-rev.7l16120 8
1 Tais 5 offidal Inspection Form:Subsurface Sewage Disposal System-Page 13 of 16
Aug 01, 2018 16:41 HP Fax I page 50
Commonwealth of Massachusetts
Title 5 Official Inspection Form
RSubsurface Sewage Disposal System Form- Not for Voluntary Assessments
51 Sea uit Road
Property Address
AI son Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every page Cq[Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a two pipe field 12'x50'. Ck D Box and camera out lines. Prob in field area. No sign,of
over loading.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspooi
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.):
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Aug 01 2018 16:41 HP Fax page 51
Commonwealth of Massachusetts
p Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Seapuit Road
Property Address
Alyson Wyqonski
Owner Owner's Name
information is Osteryille MA 02655 7-30-18
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cant.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5insp.doc•rev.712MOI8 Title 5 Qffidal Inapediion Form:Subsurface Sewage Disposal System•Page is of 18
Aug 01 ,2018 16:41 HP Fax page 52
<C` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t�
51 Seepuit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every page. CityiTown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference.
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
N'r
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t5insp.coc•rev.726f2018 Tithe 5 Official Inspection Form:SubaWsce sewage Disposal system•Page 16 of 18
f
Aug 01 ?018 16:41 HP Fax page 53
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Seapuit Road
Property Address
Alyson Wygonski
Owner Owner's Name
information is required for every Osterville MA 02655 7-30-18
page. Cltyfrown State Zip Code Date of Inspection
D. System'Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
No
Estimated depth to sigh ground water: feet
0-g
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: 1996
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.1996 10'-6" no G.W.. Bottom of field at4' below grade. Bottom of field at 6-6"above T.R.
Depth.
�I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fom:Subsurface Sewage Disposal System•Page 17 of 18
Aug 01 2018 16:42 HP Fax page 54
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Seapuit Road
v Property Address
Alyson Wygonski
Owner Owner's Name
information is Osterville MA 02655 7-30-18
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp_doc•rev.712612018 Title 5 Olficiai Inspection Form Subsurlace Sewage Dlsposal System•Page 18 of 18