HomeMy WebLinkAbout0454 STARBOARD LANE - Health =ST.,ARBOARD LANE,`OSTERVILLE
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - ,
454 STARBOARD LANE ;<
ifyk4d
BOWERMASTER ALLAN H &BARBARA L-TRS '
Owner information is Owner's Name
•equired for every page. OStervllle MA 02655 3/11/18. x
Cityrrown State Zip Code Date of Inspection
Ingnprtinn rpgifltc miita±hp%iihmittpri on thiq fnrm_ Incnpr+inn forme mt ;tv not hp_ altprprl in anv
way. Please see completeness checklist at the end of the form.
Important:When filling gut forms on the A. General Information
-omputer,use only the
tab key to move your 1. Inspector:
cursor-do not use the
,etum,key. Robert Paolini
-- Robert Paolini Septic Service
Company Name
VI 17 Playground Lane
r.mmnnnv Arfrlraaa
Yarmouthport MA 02675
.City/Town State Zip Code
508 362-3555 S14454
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
i iaiti v is 5ai v:nia siii:
0 Passes ❑ 'Conditionally Passes ❑ Fails
❑ Needs Further Ev luation by the Local Approving Authority
Inspector's Sig 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
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****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 'rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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1
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER ALLAN H & BARBARA L TRS
Owner information is Owner's Name
•equired for every page. Osterville MA 02655 3/11/18
Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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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
inriit-nfori hctrnei
Comments:
The septic system is in proper working order at the present time.
' {..Ij ��66L{iY iiL{B4Af ii VB{Gi1i� Y iy LJL�3.
❑ 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 -
\dLiirf.111fi ILii, t./fVGJV VIIF%li.i11 I.
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.
Compliance indicating that the tank is less than 20 years'old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER, ALLAN H & BARBARA L TRS "
Dwrier information is Owner's Name
equired for every page. Osteryllle MA 02655 3/11/18
City%Town State Zip Code Date of Inspection
B.. Certification (cunt.)
i_i r`uliiN G faliiuef 133uiiIF?J%aldliiIJ fIUl upefailul-lai. 6yslefii Will Nab3 Wilii buafU(ii i-ieaiiii aNNfuvai li
pumps/alarms are repaired.
"
B) System Conditionally. Passes (cunt.):
❑ 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
' if iAJJ 11 iJi.JYYLIVI i if \YYILi i fAFi i✓i V YLAI \Ji I..i VLwl V Vi 1 iYLAi Li i%.
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
r l Aiefrihi ifinn hnv ie Ievelerl nr renhnorl n V I--I .nl F1 till /Gvnl�in(�elnu.\•
u i 1 le sy&iel t l f equlf ud pul-iplf Iy I'l-1 e ii fai i 4 Ufl ieS a ywal due lU bi Okefl ui UU31f,iiC;lCtl f3IP-e(6). 1 11e
system will pass inspection if(with approval of the Board of Health):.
O broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N . ❑ ND (Explain below):
i
C Further Evaluation is Required b the Board of Health:
f a v
❑ 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:
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❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER ALLAN H & BARBARA L TRS
Owner information is Owner's Name
equired for every page. Osterville MA 02655 3/11/18
Cityrrown State Zip Code. Date of Inspection
B. Certification (cunt)
L. Vy-i G•i.i{i iiii iiG iU{i Yiiii..iii iGGY iiVUiY Vi i IiriiAi4{{ `UiIY i YGJi{L i6Yii.i i,iYii F(iYa.{, 6i Uiiyj r
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
❑ 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-
.- _ .
i I lly..y.iiV.ill p:uJJV.v if it i'v YY' ,a YY—, ui —y�ii J, i.:: VI Ili _ —1 , —Vi ♦rvl llli— l---1 lit y, iVl i'v 6.i.ii
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:
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You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
ri n Backup of sewage into facility or system component due to overloaded or
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❑ , 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 0 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
ik--1/ AJ A.....
t5ins-3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER ALLAN H& BARBARA L TRS
Dwner information is Owner's Name
equired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0- - Any portion of the SAS, cesspool or privy is below high,ground"water elevation.
n n- Any portion of cesspool or privy is within 100 feet of a surface water supply or
lriviiiAiy iv a 3Ui YVUiVI aUppiy.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ n 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 qreater than 50 feet
from a private water suppiy.weii 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.]
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10,000gpd.
❑ E 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.
L.j Lail i`.,L 6i j,ViLiiiO. i V s!L YVii 3i ViLi VVi.Gi iaii.�.y Y3�vai.ei6 iiiY J�oGviii ii iiJG�Vi 4i. Y Oif Viiii� YYliiii Bi
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
L_ Li is 5y5i�i�I 13 VV i'thlll i'tliV ICQI i+F Q JUi ICIi e,UI iI Ir\i7 ig YVu sup pry,
3Upiy
❑, ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection
El El Area—IWPA)or a mapped Zone II of a public water supply well
J
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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER, ALLAN H& BARBARA L TRS
Dwner information is Owner's Name.
inquired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
C. Checklist
y11VVfi it lift/ iV1iV YY ii il�. I1UYV illi•L�1 131�11ii. I VV YiY.iG IIiVIVUIV r'vJ IIV UJ ii%liUl,li li i lli-v iiJ 11V YY li iy.
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
r-1 n %Alore cinv of thin evefam nmmnnnonfe ni imnorf ni if in the nroVini ie f%A/n uieelroY?
❑ ❑x Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑x ❑ Were as built plans of the system obtained and examined? (If they were not
..:L.L.h.... ...,.. AI/A\
❑x ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑x ❑ Was the site inspected for signs of break out?
❑x ❑ Were all system components, excluding the SAS; located on site?
i_i LJ YYCI C li is Qsapb :lark i f lai ii i0leS OF iGoVC•1 ed, VfAL-1 IOU, U1 iU Li It; ii 1[G1 IV! UI tile laI k
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑x ❑ 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
VirV{1 ViVfilili iVid VUJ\.rM Vi 1. -
❑x ❑ Existing information. For example, a plan at the Board of Health.
ElDetermined 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. bystem int®rmati®n
Residential Flow Conditions:
i
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
utSiuN iiow based on 31u Gift 15.203 (for exampie:'110 gpd x#or bedrooms):
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 454 STARBOARD LANE
BOWERMASTER, ALLAN H &BARBARA L TRS
Dwner information is Owner's Name
,equired for every page. Ostervllle MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
D. System Information
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Seasonal use? , 0 Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): na
Detail:
❑
Sump pump. Yes ❑ No
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Inr6 ictrinl vuneto hnlrlinn tnn4 nrocent7 I-1 Voc F-1 Kin
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins:3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17,
k;01i1Ut-101-jWraiiti yr ivlaSsaCUIUSeUd
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER, ALLAN H &BARBARA L TRS
Owner information is Owner's Name
•equired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
LUZA UiAiV Vi LA;L;UlAi.il i.,yi U.-—r.
Date
Other(describe below):
VP+PPYPiaP Pt if VYiiiP�iYiifi
Pumping Records:
Source of information: Scott Frank
W-MC evefem nr imnerl me n-mrf of fhe incner4inn7 n vee 1-1 Aln
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? measured,.
Reason for pumping: Maintenance
P 1r.i4 i6i y�Ji4-ii i. ..
Septic tank, distribution box, soil absorption system
❑ Single cesspool
(-1 (lvcrflnur r•ceennnl
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current L operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER ALLAN H & BARBARA L TRS
Owner information is Owner's Name
equired for every page. Osterville. MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
uy uu �.v,,,tsv,,�.,av, uucc.. ,:saw,�.wi �ii ,",v�ii ij ui i:.i:wui-w:.;i i`iivi Fi iuu::i i.
Were sewage odors detected when arriving at the site? ❑ Yes F No
Qedlefinn Ccuinr nn cite n1nn1•
Depth below grade: 2'5'
feet
Material of construction:
❑cast iron ❑x 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence-of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the building vents.
r,Ui;1i;; i ra v v p k;i iI. .
Depth below grade:
1
feet
Material of construction:
n rnnr•rctn 17 mctMl n fihcrnhcc r_1 nnlvcthvl arum n other/cvnlnin\
-
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 100
ch vine ricn+h
311
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
sV•,r 454 STARBOARD LANE
BOWERMASTER ALLAN HA BARBARA L TRS
Owner information is Owner's Name
,equired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Quiput; itii iii kuui a.) -
Distance from top of sludge to bottom of outlet tee or baffle
4311
Scum thickness
8"
511
niefonre from +nn of eni im+n+nn of ni i+le++ee nr hnffle
511
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
..1-4-4 i.. ...�41..i ..r4 _ .:A..........F L...L...... ..i.. \.
Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
• �a"a:aeo"r' :7u�s`-i;iisi:cii:iii:uiii:riui:�.
Depth below grade:
feet,
Material of construction:
n nnnr ro+e n me+-m1 n fihernhec I—I nnlve+hvlene r-1 n+Fier/evnloin\
Dimensions:
Scum thickness
• it fJ\i..if iV"v 1l tiiii \V+J\Ji JVlAi ii lV iVI.J Vf Vi.ili Vf,l:rV Li FJiiliiv
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
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER, ALLAN H & BARBARA L TRS
Owner information is Owner's Name
equired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
V V:1111itrl llJ`Uii L/UI1 lrJfl ilJ, i'v l.iilill li"viiUUII V:IJ, allVi UliU VUiIVI ila..VI liLlf li"v VVIIUIiI\i11, JiIUVLUI CiI f:ala91 LLY,
liquid levels as related to outlet invert, evidence of leakage, etc.):
9i�iii Vi iiiiYGiYY ii�. iilYi7�iUilli IIiUVI NL t./Uillt•J'vU Ui llliii.. VI li lit.JLLiI V::` `li.iir:..:�v Vli Jlii.. Fr1vii�.
Depth below grade:
Material of construction:
I—i rnnr•re+e F-1 me+ol I I fihernhec i-i nnhre+hvlene n n+her/evnhinl
Dimensions: -
Capacity:
Design,Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in.working order: ❑ Yes No
✓i.i:C:u; lug.i.iawiii.ii(iy.
Date
Comments(condition of alarm and float switches, etc.):'
-Attiaa,t:upy oil cur ferlt Pui I1pil Ig Golitl aci(F equir ed). is Copy atidac li d. a `i es iLj NO
t5ins•3t13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
`r01 it-11011weaftil (it IMIdS�dli:ilu5e[gi
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER ALLAN H & BARBARA L TRS
Owner information is Owner's Name
•equired for every page. Osterville MA 02655 3/11/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
a.+fisu iaiY aivn i.avta�u rl VJLa n i i lu.al a.\.Vri:i iviij �ivi.iwi:: Vi i Jiw rlui ij.
Depth of liquid level above outlet invert No
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is level.Noevidence of solids carryover.No enidence of Ieakage.Box has one outlet lateral.
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
rnmmGnf0 /nnfo_nnnrfiflnn of ni imn t-h-nmhar r�nntiifinn of ni imne onri onni irtnnonf`CC cfr�`'
ii rdaiilifJJ V Yiil iiiJ iAiV IIVL Ili Vfi VII\.11\�. VIWVi, JYJLVIIi iJ fA VVI IV fal Vilai 'JaAVv.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER ALLAN H & BARBARA L TRS
Owner information is Owner's Name `
•equired for every page. Osterville MA 02655 3/11/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
6'x6' H2O with 2'
leaching pits number: stone.-
❑ leaching chambers number:
r� Ic�rhinn n�llcricc . • ni imhcr•
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
L_,.1. IIIiiV alivaiaitaiiiQlive syslem", - -
Type/name of technology: '
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.No signs of hydraulic failure.Leaching was dry at time of inspection.
va:`.i's-�vvii`.s�i:::iiiil'Jis'vi iii::ui uL:fiui i ipii:ii ciu i✓ui i,iii ii iii i.i i:i:iii.iii� kiUL;Uii:i7i i iiiii.:
Number and configuration
Depth—top of liquid to inlet invert
rlen+h of cnlir+e hoer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE .
BOWERMASTER, ALLAN H & BARBARA L TRS
Owner information is Owner's Name
•equired for every page. Ostervllle MA 02655 3/11/18
Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
1 U1UUfili tUfiUl V, IVVVI VI �/1IUII i , LVtiUlltVil YV lilC[ii4fi;
etc.):
i i6IIr `I--ifii J;[V viw i).
Materials of construction:
Dimensions
nonfh of enlirie
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition'of vegetation,
etc.):
ti
Commonwealth of Massachusetts
Title 5 Official: Inspection Form
Subsurface Sewage Disposal:System Form-Not for'Voiuntary Assessrhents
04 8TARgU-ARU- LANE
Propeq Address
BOWERMASTER•.ALLAN:M &BARBARA L TRS
Owner Informabon is
Owner's Name.
equired for every page:
Osterville MA 62655.6 3/11118
"/Town State Zip?Cade Date of Inspection_
Sketch Qf Sewage Disposa(System;provide a view of th sewage disposal system, includipg`ties.to
at least two permanent reference landmarks or bendimark.s. Locate all wells within 1 feet. Locate
where public water supply enters the builoing. Check one of the b6xes_below-
O hand4ketch in the;area below:
Li drawing:attacneo separa''.ety
o
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER, ALLAN'H & BARBARA L TRS
Owner information is Owner's Name
equired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
a/i cti V�iisa a.
0 Check Slope -
N Surface water
n ('hcn4 ncllor k
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 10'
feet
Please indicate all methods used to determine the high ground water elevation:
u uoia.aiiicu a orn sysla i i uesig i f+i i i�o i r 6co a
If checked, date of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Ivl /'h....I,...4...41, 1---I Q.,. A --F Ll....lih ....L.;...
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater
elevations.
--.-._._.__--_.._ �......:. . ._._....--- ._._.. ..Y_ ___. ___.e. .._.._._
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t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
ire\ irUi11111U11wedlUll of IVIi.1b5 dullubeub
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
454 STARBOARD LANE
BOWERMASTER, ALLAN H & BARBARA L TRS
Dwner information is Owner's Name
-equired for every page. Osterville MA 02655 3/11/18
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
i=i inspeuion jtii I ii i ictt Y. fi, U, U, U, OF C la IrrtGi{ U
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑x System Information:—Estimated depth to high groundwater
Iv1 A C as l-<J : a ca
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
�c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property '45`1 5I�i boc�r�l Lace - Os1 erv•�l�
Owner' s name JT _rr j Po.mer j
Date of Inspection ki I Q, Gas RECEIVED
11�,PaEIV D
PART A
CHECKLIST J U N 9 1995
Check if the following have been done: HEALTH DEPT
TOM OFBARNSTABLE
✓ Pumping information was requested of the owner, occupant, and Board of
Health.
✓ None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓
The site was inspected for signs of breakout.
i p
All system components, excluding the SAS, have been located on the
site.
t✓ The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
✓ The facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
t ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8
PART 'B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential')
3 number of bedrooms
_ number of current
residents
\NU garbage grinder yes or no
_ laundry connected to system, yes or no
e5 seasonal Use- es or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
mos+1 j
GENERAL INFORMATION
Pumping records and source of information:
UPU
NO System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
—ram Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
i o 6Lr 61 -1 - W n e r
1.J 0 Sewage odors
g detected when arriving at the site, yes or no
a
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: I 25 96A
(locate on site plan)
depth below grade: l � "
material of construction: P"' concrete metal FRP other(explain)
dimensions: _S ' X I G ' X 5' r( "
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
GF 0nd, h Dn
DISTRIBUTION BOX: !"
(locate on site plan)
EyeI7 depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
S3
L
10 S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : t'
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
No ,5i]Vo o j� h�edraullc -4a lure,
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for. maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
B
A
D Box
0 0
Tank
A B
Pit 16' Tank 15'
29' D box 15'
31 ' Pit 29'
DEPTH TO GROUNDWATER
? ' depth to groundwater {'r o�, bo Hom of p,t.
method of determination or approximation• Fr.rn p10�' m�shod
M i w 0,9 ada,us�r-j RP i`i 1 . IAliS wn_11 dcAJ .
A
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
N Backup of sewage into facility?
N Discharge or ponding of effluent to the surface of the ground or
surface waters?
K/ Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
01 N Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
K below the high groundwater elevation?
within 50 feet of a surface water?
N within 100 feet of a surface water supply or tributary to a surface
water supply?
N within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
N within 50 feet of a private water supply well?
_A less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
f
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector 81161 /-10�[t
Company Name ,�ho�e�i ✓� na��v�T� �n
Company Address /7 pin �Sfre,e f
od to
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
f/ I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature � � �✓�
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
r
vov
LOCATION SEWAGE PERMIT NO.
�( , Z °.6 tom/ e- - 7/
VILLAGE
�sT�le� ► �.� f,
INSTA LLER'S NAME_ ADDRESS
B U I L D E R OR OWNER
L-1 fZ ti .S H->EL 6411
DATE PERMIT ISSUED a -
DATE C 0 M P L I A N C E ISSUED / 0
o i
F ��'r'
t
�� t
No........ ;f f Fps............. Q�
..... 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..........................................................................................
Apli iration for Bispvii ai Works Cnnnitrurtinn t1trutit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
... ..... ..................................
cation-Address
lr .✓.�l.l`. _ �? N� a o
V� i r yl..d.
7 M/ �
-- ---....... lr..................-...... 1
Address
a _........... . O �r Mom....................... .............-...
Installer Address ...............
Type of Building j2 lJ h '
j Size Lot.--_-:.0 .. :_. et
- a Dwelling—No. of Bedrooms............................................Expansion Attic (%v� Garbage Grinder (%y)O
p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------...---------------------------------.._..---•--.
W Design Flow_._..._.`...._ ........ gallons per person per day. Total daily flow____.__..�.1�.. .......................gallons.
WSeptic Tank—Liquid capacitvl450.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—,No..................... Width....*------------.- Total Length.............T..... Total leaching area.....p..........._...sq. ft.
3 Seepage Pit No...........1-------- Diameter.... __......... Depth below inlef_.....&........ Total leaching arealll_Ar'_6 sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by............................ -:e_.:..._.........._._....._. Date.... ��_-�_..... _..
1.a Test Pit No. 1--------�L.....minutes per inch Depth of Test Pit....�I........... Depth to ground water.......J:!_Z'.--__.-
(Z4 Test Pit No. 2.._.._._I_minutes per inch Depth of Test Pit.... _... Depth to ground water._f Z.._ tcc?....
cc.,,c ��„ --- ------------------------------...� ------
O Description of Soil------..�... --- •..�-- ---------
` �
W ----••---------------------------- ------•-----•-------g--•----•------------•------•-•--•--•--•---••-•- --• •-•----•-------------••-................
UNature of Repairs or AlteratiPns—Answer when applicab ...__ -____--__ ...t�/ •* G -�,.�.. rss -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIL 5 of the State Sanitary Code— The under ' ned further agrees not to place the system in
operation until a Certificate of Compliance has b issue by the b r ofsI eal`l. �j� T /�3
Signed --------•--•......---•-•--•--...-• Y"-'�: Q.---------
ate
Application Approved By............. w--- •• . -- . . .......................................
r�-,'
Date
Application Disapproved for the following reasons------------------------------•------•-----------------------......-------------•----------.........--•..._......
-----------------•----......------.........-----•-•---------•------------•--------------------------••---
Date
PermitNo....................................................... Issued_.........................-.............................
$ Date
No........ _ :2Z t FEE..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................-,,.........OF....................................... -
Appliration for Elhipaii al Works Cnayattitrurtivat Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: '
................_................................................................................
-•-...•-----........----._............--•-••-•--------•--•••-----••-......-••••-••._.........-•-•-
Location-Address or Lot No.
i
Owner Address
W
Installer Address
� Type of Building Size Lot............................S q. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria
04 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 ( )
aPercolation Test Results Performed by--•••---•-••--•-•......................••-......-••--•...--•-----•-•••... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit---.--.............. Depth to ground water..---.---------.---.----
G%, Test Pit No. 2................minutes per inch Depth of Test Pit--............. Depth to ground water------.-----------------
..................................
---------------
•-----------------........_._....--__---_-_--------------•--•-•-•-----....----._...........
-----------------
0 Description of Soil........................................................................................................................................................................
W
U ..........................................................•••------------•----•----•----••.....•-•-•--•-•••••-------•-•---•---••-----•-•---...........................................................
VNature of Repairs or Alterations—Answer when applicable,-44_"r-'� ..40---�•Js �a,� -- ,emas,,t._. �1'.-
o v _ Y �``"`"` /
x ----;cam. �= --::. . .,. �• ----------------------------------------------------------------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions 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 issued by the board of health.
Signed....................................................................................... ................................
,�-�- D to
Application Approved By............. - --- ----------•-
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------•--••-
-•---------------------------------------•--•---•--••----•.............................................................................................................................................
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....:.....................................OF...................................................................................
(Irrtifiratr ,af flu t �i �trr
THIS IS E IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------- -------------•--••--•-•.........--.•.•-• ....----•-•-•••----••-------------...............•--.....................---------------............._........._
/ Installer
at..................................... .
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit '`.--__-------. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WIVI FU)(CTION SATISFACTORY.
DATE..... a! ° '?
.................................................. Inspector.... ..- •--------------------------•----....._........._................._......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No... ..t�:.. ... FEE...... ............
Utoposal Work 0"lomitrudian prrutit
Permission is hereby granted.......... . .
to Construct ( ''or Repair ( an Individual wage Disposal ,Sstem
atNo... ... s•�,�r -•--• ----•--....._.�-s4----------------------------------------------------------------•----•----...-
Street
as shown on the application or Disposal Works Construction Permit No.................j._ Dated..........................................
oar of Health
DATE.... �
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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