HomeMy WebLinkAbout0065 STARBOARD LANE - Health 65 STARBOARD LANE, OSTERVILLE
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Commonwealth of Massachusetts
_ v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
65 STARBOARD LN �7
Property Address
a fX
SIGEL
Owner Owner's Name R,
information is required for OSTERVILLE a MA - .12-4-14 '
every page. City/Town State, Zip Code r Date of Inspection ° t�
3)
Inspection results must be submitted on this form. Inspection forms,May snot be altered in any
way. Please see completeness checklist at the end of the
Important: A. General Information '
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN -
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address T
CENTERVILLE a 'MA 02632
City/Town State Zip Code
508-420-4534 • . SI4297 -
Telephone Number License Number
B. Certification x
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 16.340 of
Title 5(310 CMR 15.000). The system:
® Passes _ ❑ Conditionally Passes ,. ❑ .Fails
❑«.Needs Further Evaluation by the Local Approving Authority
12-4-14
o 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
r at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Offici s tion Form:Subsurface Sewage Disposil System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,M s 65 STARBOARD L•N r '
Property Address
SIGEL
Owner Owner's Name
information is '
required for OSTERVILLE MA t 12-4-14
every page. City/Town State Zip Code 'Date of Inspection
B. Certification (cont.),
Inspection Summary: Check A,B,C,D or E/always complete•all'of Section`D
A) System Passes:
{ T
® 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 a .
indicated below. = >
Comments:
SYSTEM MET ALL-PASSING REQUIREMENTS AT TIME OF INSPECTION.,SYSTEM APPEARS
TO BE ORIGINAL. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN
NOT BE DETERMINED FROWTHIS INSPECTION - a`
y F
B) System Conditionally Passes: '
❑ One or more system components as described in the"Conditional Pass"-section need to be r
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. M
*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 ElND(Explain Below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
M 65 STARBOARD LN
Property Address ,
SIGEL
Owner Owner's Name
information is OSTERVILLE MA_ 12=4-14
MA-
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. Systernmill
pass inspection if(with approval of Board of Health):
❑ brokenpipe(s)are re laced Y N ND(Explain below):
P ,❑ ❑ ❑ ( P )
❑ ", obstruction is removed ❑ Y ❑ N-- ❑ ND(E)eplain below):
distribution _-
❑ box is leveled or re laced Y N, ND(Explain i a n below
❑ The system required pumping more than 4,times a year due to broken or obstructed I e s . The•f
system will pass inspection if(with approval of the Board of Health):
El broken pipes)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 Boardfof Health in order to determine if
r the system is failing to protect public health,:safety or the environment.
1.:System will pass unless Board of Health determinesin accordance with 310 CMR.,a
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
t5``ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `
°M 't 65 STARBOARD LN
Property Address
SIGEL
Owner Owner's Name .. s
information is
required for OSTERVILLE MA 12-4-14
every page. Cityrrown State Zip Code Date of Inspection .
B. Certification (cont:) A
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:
0 The system has aseptic 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. `E
❑ 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. f
❑ 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. , r
3. Other:
D) System Failure Criteria Applicable to All Systems: r,
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
Liquid depth in cesspool is less than 6" below invert or available volume is less® than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17'
r t
Y
f -
Commonwealth of Massachusetts
k
Title 5 Official Inspection Form I M
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 65 STARBOARD LN c
Property Address
SIGEL
Owner Owner's Name
information is OSTERVILLE 'MA 12-4-14
required for
every page. City[Town State Zip Code Date of Inspection
B. Certification (cont.")
Yes No .
El ® Required pumping more than 4 times in the last year NOT due to clogged or ;
obstructed pipe(s). Number of times pumped: 4
❑ ® Y 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.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supplywell:
' s
El
® 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 IY -
Yes No
❑ ❑e the system is within 400 feet of a surface drinking water,supply.
El ❑ 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 ll of a public water supply,well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate. .
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 5 of 17 +
Commonwealth`of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 L STARBOARD N
�M O
Property Address
P Y _
SIGEL
Owner Owner's Name
information is d MA 12-4-14
required for OSTERVILLE
every page. City/Town 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, occupapt, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks? '
❑ - ® A 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?
®! El available
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:oibedrooms(design): 3per as Number of,bedrooms (actual): 3
built
DESIGN flow based on 310 CMR 15.203'(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 STARBOARD LN
Property Address
SIGEL
Owner Owner's Name
information is OSTERVILLE MA . 12-4-14
required for - "
every page. Cityrrown State Zip Code, Date of Inspection
D. System Information
Description: `
A septic tank that appeared to be 1000 gallon was located along with a leach pit. We are not
responsible for un documented septic components that may or may not be on the property
Number of current residents: ♦ "`
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection Yes El No
information in this report.) El
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): _
Detail:
2013---------627 2014-----353gpd( house has irrigation system)
Sump pump? x El,Yes ❑ No
Last date of occupancy: date
Commercial/Industrial-Flow Conditions: . . r,
Type of Establishment: ' mP
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): 'r
Grease trap present? El Yes. O;,No
r Industrial waste holding tank present? ❑ Yes',❑. No,
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: . r
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments
65 STARBOARD LN '
M }
Property Address a
SIGEL r t
Owner Owner's Name r
information is required for OSTERVILLE MA 12-4-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use '
' Date •
Other(describe below):
j >:
71
',General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons f
How was quantit
y y pumped determined? •
Reason for pumping: ;
Type of System: . j
❑ Septic tank, distribution box, soil absorption system,°
❑'• Single cesspool : .. .
❑ :Overflow cesspool '
❑. Privy
' ter.. • - . e. :` • : ,. •. . ,
❑ Shared system.(yes or no) (if yes, attach,previous inspection records, if any); .
❑ Inriovative/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): y
tank and pit no d-box
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form 4
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 65 STARBOARD LN
Property Address
SIGEL
Owner Owner's Name
information i s
required for OSTERVILLE MA 12-4-14
every page. Citylfown State Zip Code Date of Inspection .
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information: `
1981 per as-built card
Were sewage odors detected when arriving of the site? ❑ Yes Z No
Building Sewer(locate on site plan):
Depth below grade: . feet
Material of construction:
❑ cast iron ❑.40 PVC ❑ other(explain): •-
G
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.): R
Septic Tank(locate on site plan):
Depth below grade:f 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: appears to beat least 1000 gallon
Sludge depth: moderated
' ' x
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form ,
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "
65 STARBOARD LN
Property Address
SIGEL 5
Owner Owner's Name > v
information is '
required for OSTERVILLE MA 12-4-14
every page. Cityrrown State. Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
♦ -
Distance from top of sludge to bottom of outlet tee or baffle
Scum-thickness. x .
Distance from top of scum to top of outlet tee'orbaffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? wooden pole
Comments(on pumping recommendations, inlet and outlet tee or baffle condition structural integrity,-
liquid
p 9 ,
levels as related to outlet invert, evidence of leakage, etc.): `
tank had no scum layer and appeared to be in good working condition'There was a deck and stone
wall over the middle of the tank that has since been removed for access. The inside of the tank was
viewed'with a mirror and appeared to be in good condition
Grease Trap(locate on site plan): } .
Depth below grade: '
• feet
Material of construction: {
❑ concrete []'metal ❑ fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness A
Distance.from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
» Date of last pumping:
Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 STARBOARD LN
Property Address
SIGEL - a,
Owner Owner's Name
information is OSTERVILLE MA 12-4-14
required for
every page. Cityfrown 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.):
recommend pumping every 2-3 yrs
Tight or Holding Tank(tank must be pumped.at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metalY ` ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: µ
gallons per day,
Alarm present: ❑ 'Yes ❑ No .,
Alarm level: Alarm in working order: ❑ Yes El, No'
Date of last pumping:
Date
Comments (condition,of alarm and float switches, etc.):,
*Attach copy of current pumping contract(required). Is copy attached? 0 Yes 0 No r
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of V'
Commonwealth of Massachusetts
- Title 5 Official Inspection" Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 STARBOARD LN
Property Address
SIGEL
Owner Owner's Name
information is OSTERVILLE MA 12-4-14
required for - ,
every page. Cityfrown 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 na
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.):
a.
•
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 al•e 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: a
d I
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form • '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 STARBOARD LN '
Property Address
SIGEL
Owner
Owner's Name
information is required for OSTERVILLE MA .12-4-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,
Type:
® leaching pits j number: 1
❑ leaching chambers number:
❑ leaching galleries number:,-
❑ leaching trenches number, length: ¢: `
❑ leaching fields j number, dimensions:
i
❑ 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.): '. - a.
pit was opened and found to'be dry at time of inspection with no signs of failure or surcharge stain
line was at about 2 ft from the bottom of the pit '
Cesspools (cesspool must be pumpe&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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 134of 17
7-
Commonwealth'of Massachusetts
Title 5 Official Inspection Form. ,
-
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 65 STARBOARD LN
Property Address t '
SIGEL .
Owner Owner's Name
information is + `
required for OSTERVILLE MA 124-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) r
Y
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: s
Dimensions .
Depth of solids
Comments(note condition of soi( signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r
' • • ' . '. .•. , a `. Y r +, ,; r . 4 .� t
t5ins•3/13 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System•Page 14 of 17,
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form-, _ ' *
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<a 65 STARBOARD LN 4 Property Address
SIGEL
Owner Owner's Name
information!is required for OSTERVILLE MA 12-4-14
every page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.) r
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 welis,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
. T
� r
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Paget 5 of 17
r
Commonwealth of Massachusetts
. Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a
65 STARBOARD LN
Property Address v.
SIGEL
Owner Owners Name
information is required for OSTERVILLE MA 12-4-14
every page. Cityrrown State 'Zip Code Date of Inspection
D. System Information (cant.)
Site Exam: '
® Check Slope F r.
® Surface water
® Check cellar a '
® Shallow wells t :
greater than 5 3 '
Estimated depth to high ground water: , feet,
Please indicate all methods used to determine the high ground water elevation:
❑ 'Obtained from system design plans'on record
If checked, date of design plan reviewed: Date
❑ "Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health explain:
❑ Checked with local excavators,installers-(attach documentation)
❑ Accessed USGS database-explain:'
You must describe how you established the high ground.'water elevation:
property sits high above the closest body of water at the back of the lot
Before filing this Inspection Report, please see Report Completeness+Checklist on next page.
t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ,
f
Commonwealth of Massachusetts ' :
- Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 65 STARBOARD LN =
Property Address
SIGEL
Owner Owners Name
information is required for OSTERVILLE MA, - 12-4-14
every page. Cityrrown State Zip Code • 'Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked,:.
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information Estimated depth to high groundwater ,
® Sketch of Sewage'Disposal System either drawn on page 15 or attached in separate,file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 2
•. Cam` /,, /- 6 Y
LOCATION P J. u`' `�`� SEWAhE PERMIT NO.
LoT /3 S72k23or92 D -G/V
VILLAGE m
IN.STA LLER'S ` NAME 0 ADDRESS
.Ti4 N1` S 7,FR gE 449 A
GUILDER OR OWNER F
DATE PERMIT ISSUED
DATE COM►LIANCE ISSUED
FRoMI
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hq://www.town#Barnstable.us/Assessing/HMdisplay.asp?mappar=165126&seq=1 12/5/2014
9
oF111KEE Town of Barnstable
�As Department of Health, Safety, and Environmental Services
9� 039�- ,0� Public Health Division
A'ED1A°�A P.O. Box 534, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508 790-6304 Director of Public Health
May 21, 1999
Morton& Vivian Sigel
80 Aylesbury Road
Worcester, MA 01609
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE BOARD OF HEALTH NUISANCE
CONTROL REGULATION NUMBER ONE
The property owned by you located at 65 Starboard Lane, Osterville, MA was inspected
on May 19, 1999, by Jerry Dunning, Health Inspector for the Town of Barnstable,
because of a complaint. The following violations of the Nuisance Control Regulation
Number One Regulation and the Sanitary Code II were observed:
410.602: Many bags of garbage and rubbish on the ground.
You are directed to correct the violation within forty-eight (48) hours of receipt of
this notice by removing the rubbish.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven(7) days after the date order is received. However, this violation
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation. You are also subject to non criminal citations of$40.00 for the first violation
and $15.00 for each additional violation. Tickets will be issued daily until the violations
are corrected.
PER ORDER OF THE BOARD OF HEALTH
rMcKean
Director of Public Health
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NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE BOARD OF HEALTH NUISANCE
CONTROL REGULATION NUMBER ONE
The property owned by you located at ( �7 �5� g..G,�I Q,�tto,,,L,�Q�, rvt,c,,
was inspected on 1997, by
Health Inspector for the Town of Barnsta e, b ause of a comp faint. The following
violations of the Nuisance Control Regulation Number One Regulation and the
Sanitary Code H were observed:
You are directed to correct violations within L/$
of receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven(7) days after the date order is received. However, this violation must
be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
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d SENDER: I also wish to receive the
:o ■Complete items 1 and/or 2 for additional services.
■Complete items 3,4a,and 4b. following services(for an
■Prd Print ourru name and address on the reverse of this form so that we can return this extra fee):
car
■Attach this forth to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
permit.
$ ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery in
■The Return Receipt will show to whom the article was delivered and the date o
C delivered. Consult postmaster for fee.
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5.Received By:(Print Name) 8.Addressee's Address(Only if requested
w and fee is paid) i
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g ,6. ' nature:(Addressee or Agent)
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PS(FoA 3811, December 1994 ... 102595-97-13-0179 Domestic Return Receipt
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UNITED STATES POSTAL SERVICE First-Class Mail l�1
Postage&Fees Paid
USPS
Permit No.G-10
c Print your name, address, and ZIP Code in this box O
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Public Health Dhdslon . . ; f�
Tiown of Bamstable
PC,.Box534
Hyannis,Massachusetts 02601 �
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LOPATION SEWAG�E PERMIT NO.
VILLAGE
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INSTA LLER S NAME i ADDRESS
.7 NIFS 7� A
5UILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED /ah2ao�/
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
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®.� ........ .........oF.:... 'TA ..... .----------------._............_.
Appfiration for Uhipasal Works Tom3trur#inu rrutit
Application is hereby made for a Permit to Construct ()4) or Repair ( ) an Indiv"idual Sewage Disposal
System at:
................__....._........C�:Pt� �Ja........ :-----=��:...... ..... -�m I� ............ :...
•-,-
ffLocation-llAddress 1,�wA -- -•-•- -••.•or Lot No.
1t.cl.l. K.•••------ L �ciiL+rl�... ..........----------
Owner Address
W
Installer Address pp �
Type of Building Size Lot_ ........__._t _=__
U Dwelling—No. of Bedrooms..............-.....__.._._____ ._.__Expansion Attic ( ) Garbage Grinder (4)
-�
Other—T e of Building No. of persons____________________________ Showers Cafeteria
Q' Other fixtures ...................................................... --- _..--
W Design Flow...............SS....................gallons per person per day. Total daily flow................. � .
Design
WSeptic Tank—Liquid"capacity-1-SCZ)gallons Length................ Width................ Diameter-_--_- Depth................
x Disposal Trench—No..................... Width___._..e..__.____... Total Length........ q....... Total leaching area...... ..........sq. ft.
Seepage Pit No-----------I--------- Diameter-------lZe._._. Depth below inlet____________________ Total leaching area..... _._sq. ft.
z Other Distribution box Dosing tank ( )
Percolation Test Results Performed .........:..... ___T- _ Date_._.11I,- ------------
aY!M ..:.�
Test Pit No. 1...... _._minutes per inch Depth of Test Pit--------_ ..... Depth to ground," ,`ater_.-------------------___
v
f14 Test Pit No. 2______ ._minutes per inch Depth of Test Pit.__._._.__ __. Depth to grount yrlater----- ...............
................................................_.
O Description of Soil..................... -----------------------
U ............................................................AA -um.W
............<4-aD....................................................................................
.........................................................................................................................................................................................................
V Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------n........................................
Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with
the provisions of TIT1.;�. 5 of the State Sanitary Code—The undersigned further agrees not to place,the system in
operation until a Certificate of Compliance has been •ssued by the board of health.
Signed=---- - ......... ------------------••----------•• ........................
Application Approved By ate
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------•-•--••--••--•-
------------------------------------------------•----------------------------------------------•-•----------------------------------------------------------------------- .................
Date
PermitNo......................................................... Issued.......................................................
1
job.-
No----------•- Fizz.........................L;�
THE COMMONWEALTH OF MASSACHUSETTS 3
�.� BOARD OF HEALTH
OF....'....................................................................................
ApplirFation for Disposal Works Tonotrurtiun ramit ,
Application is hereby made for a Permit to Construct (I`) or Repair ( ) an Individual Sewage Disposal
System at:
�l Location-Address --- _1 or Lot No.
................••-•-•..._.......f.::.=:r::�:�...•••....... i, 1.'.��?... ..............................................
Owner Address
W
Installer Address
QType of Building Size Lot............................Sq-feet'
U Dwelling—No. of Bedrooms.............3_.._...._...__ .._..Expansion Attic ( ) Garbage Grinder (4)
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other futures `....... --------- ;
W Design Flow.................?'.tea..........,......___.gallons per person per day. Total daily flow.................:'_'�?.0.............gallons.
WSeptic Tank—Liquid'capacity!...2 .gallons '\Length................ Width................ Diameter................ Depth................
x Disposal Trench—Nj. .................... Width........A.......... Total Length.................... Total leaching area......A;..........sq. ft.
Seepage Pit No.......... .......... Diameter.......[Z...... Depth below inlet......_=............. Total leaching area.... ....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results erformed by.._?� VT'e............ _......r�.___.c'�� r t''_. �.-_-•--__-...
a ' Date... ;�
Test Pit No. I....._.�•-....minutes per inch Depth of Test-Pit........_,Z.... Depth to ground �ater.._...`"..............
Test Pit No. 2..........—...minutes per inch Depth of Test Pit...........Z_.. Depth to ground water...._.................
R'+ •...........................................................•--•---_......................_•••-••--•.........................................................
O Description of Soil.............................1
---------------------------------------------- l � Wl--------- ..........................................................................................
(�- L'
..................................................................,_._--.--.._._......................._........--........---...---.....___............._.._..._......_..........._......_...._.._......
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------------------------------------------------------------------------------------•-•--------•-----
AgreiQment:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal"System in accordance with the provisions of TITI,;�. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a.-Certificate of Compliance has been issued by the board of health. ,
Signed. ..................................................................... ---•----------------......
N/�" elf41J Date
ApplicationApproved By----•--•---•------•----- ........... -------------•- ••-------••-------•-----
9/ Dat 2.
Application Disapproved for th 'n 'yecb"ons ""�j yy /<••Z:, e�°�r
----------------------------------------------------------------•------------------------------........._..-------------------------------------------------------------- ------------------------------- a
Date
PermitNo-------------------------------------------------------- Issued-.......................................................
Date
d
THE COMMONWEALTH OF MASSACHUSETTS
BOARD gF HEALTH
..........................................OF................ °t.0O�I 1 r�P>LZ
.................................................................
(115rrtif iratr of TompliFanrr ..
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by.............•--••-•--•••••••-------...--•--•-..........._.......-••••................-----•----------------...••-•-•••••-•••-•••-•............•--......•--i,✓=--••....-•-•-••-•••-•••-•---•--••--
Installer
at ......---•..... . .--••---------------•-••---••--•----••-•--•--•-•-••------•---•-•---------•-----•---------•----------------•---•-----------------•-•.......-------•------ .>
has been irf4Wed yrrt'a Gordan ,> c�e� .9/lsion6 TZT127s, State Sanitary,Code as described in the
application for Disposal Works Construction Permit No..--..................................... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL h&VIDE,T.411STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... � .1............... Inspector '...........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD (0 HEALTH
No.. FEE.........
Disposal Works Tonotrttrtiu antit- �
Permission is hereby granted---------------- = .....................- ...... ... ..............................
to Construct ( ) or Repair ( ) an Individual Sewage DisposM-Sysf'`r�
at No. ........................
....-----•••---`--- -.--. -----•-------------------------------------------------•-•_...
' -� -1 r 'as shown on the application or zspos orks on tfuction rrtl Dated..........................................
,- --•-------•---•---•-------•- ............................................................
Health
DATE..................................4............................................F- "s
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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