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HomeMy WebLinkAbout0028 STONE HORSE ROAD - Health 21 �:tonehorse:Road t Osterville�, p A = 142 WO �I r it C k o c Commonwealth of Massachusetts d 770 Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments : r' 28 Stone Horse Road . Property Address Anne Kern Owner Owner's Name -r.3 information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection U1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, 1 T use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation tab Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number � I B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-22-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of`inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 28 Stone Horse Road M Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 < 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: ® 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: System consists of 2 cesspools in series with 2 leach pits and was in working order at time of inspection. No design plans were found at Barnstable Board Of Health. ar I B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound., not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑- N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code . Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ -ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑'N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 Peet but 50 feet or more from a private water supply well". Method used to determine distance: , ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: r D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters- due to an overloaded or clogged SAS or cesspool . ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17_ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ _ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contacfthe 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, iri addition to the questions in Section D. Yes No' ❑ ❑ -the system is within 400 feet of a"surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system.is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the , system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 28 Stone Horse Road Property Address P Y Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. CityTrown 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® 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: I ❑ ® Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: , Number of bedrooms (design): l design la — Number of bedrooms (Actual) 5 pla _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA !Sins•1113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 E Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage See below 9 ( y 9 (gpd))� Detail: 2015- 118,000gallons 2016-'331,0009allons r Sump pump?. 1 El Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions:' Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap.present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 0 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information " Pumping Records: Source of information: Owner- last pumped May '17 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Pump slip Reason for pumping: -.Cesspools (part of inspection) 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) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Cesspool-cesspool- leach pit-leach pit in series t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Approximate age of all components, date installed (if known) and source of information: Unknown due to lack of records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: NAfeet Material of construction: ®concrete El 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: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 28 Stone Horse Road 7M Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): "Depth below grade: NA Material of construction: ' El concrete. El '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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day r Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is re Osterville Ma 02655 6-22-17 wired for every 4 page. Cityrrown 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.): 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (2)6'x6' ❑ leaching chambers number: ❑ leaching galleries number.- El leaching trenches number, length: - ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Both pits were dry when viewed. Cesspools (cesspool must be pumped as part of inspection)'(locate on site plan): Number and configuration 2.in series w/2 pits �i Depth-top of liquid to inlet invert b (1ST 6" to invert) (2nd T) Depth of solids layer . (1st 8„) (2nd 0") Depth of scum layer (1st 2„) (2nd 0„) Dimensions of cesspool `Both 6'x8' Materials of construction Both made of blocks Indication of groundwater inflow ❑ Yes Z No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' Comments (note condition of soil, signs of hydraulic failure, level of;ponding, condition of vegetation, etc.): . Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f, ^ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cone.) 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 - I REAR i LP ` A B DECK D Al-24' B1.46' A2.35' B2.28' A3.53' B3.18'6" A4.56' B4.13' C A B LP CP CP t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 l f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments %M 28 Stone Horse Road 4 Property Address Anne Kern Owner Owner's Name _ information is required for every Osterville Ma 02655.- 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >3' below SASfeet 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: A hole was augured 3' below bottom of system and no ground water was found. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 28 Stone Horse Road Property Address Anne Kern Owner Owner's Name information is required for every Osterville Ma 02655 6-22-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist X 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 t t K COMMONWEALTH OF MASSACHUSETTS RECEIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO MAR 2 4 2004 b MAP I `1 � TOWN OF BARNSTABLE h �- -� HEALTH MPT. PARCEL • O 4�M SJOv - LOT • TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner's Name: ANNE MARIE SULLIVAN Owner's Address: PO BOX 343 OSTERVILLE MA 02655 Date of Inspection: 3/15/04 <41 Nam f e o Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Tittle 5(310 CMR 15.000). The system: X Passes _ Conditionally .9ses _ Needs Furth / valuation by the Local Approving Authority Fails r Inspector's Signature: Date: 3/15/04 The system inspector shall submit jl,opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectf the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shbmit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title S Incnentinn Fnrm 6/1 S/?000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a 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. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3,of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a i r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 1I 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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X 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 available note as N/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? X _ 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? 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 been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S .. Page 6,of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):,J44- ` � 3V 0 a Sump pump(yes or no): NO <1 5 7l Last date of occupancy: n/a v 'U`i I ,,U%� V V v COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):YES If yes,volume pumped: 1000gallons--How was quantity pumped determined?CANCO Reason for pumping: MAINTENANCE TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system X Single cesspool X Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 30 YEARS,NEW LEACH PIT 1994 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 0" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: n/a Sludge depth: n/a Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid_ levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a I f R ' Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' W/2 FT.OF STON leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a 6' X 6' BLOCK CESSPOOL overflow cesspool, number: 1 n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): OVERFLOW AND LEACH PIT ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. NEW PIT WAS EMPTY AT TIME OF INSPECTION.THERE ARE NO STAIN LINES,INDICATING PIT HAS NEVER HAD ANY LIQUID IN IT.BOTTOM IS AT 9FT. CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert:At Depth of solids layer: 8" Depth of scum layer: 1" Dimensions of cesspool: 6' X 6"' Materials of construction:>d& (110 C l[(— Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFUL LIFE. PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a 4 Page,10 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. o.. E DOC 0�--Qo 2q P-A q � Zq to Page.I1 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 STONEHORSE ROAD OSTERVILLE,MA 02655 Owner: ANNE MARIE SULLIVAN Date of Inspection: 3/15/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER-12+FT. i 11 Commonwealth of Massachusetts IVl P /t2 - 0 7d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Stone Horse Rd f' Property Address t-" P^ti9 Kern r-h Owner's Name z• Osterville I/ MA 02655 5/7/15 City/Town State Zip Code Date of Inspection ;a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536' CitylTown State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/7/15 Ins gttrrs ig re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow.of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �JS 28 Stone Horse Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System•Page 1 of 15 V r Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 28 Stone Horse Rd Property Address Kern Owners Name Osterville MA 02655 517/15 Citylrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Cesspool to 2 overflow pits 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 28 Stone Horse Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑. distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. '❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 28 Stone Horse Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: n/a D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® 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. 28 Stone Horse Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or."no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 28 Stone Horse Rd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 28 Stone Horse Rd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection form Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 6 DESIGN flow based onv310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? 0 Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 28 Stone Horse Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 CityrFown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: no recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Cesspool to 2 overflow pits Approximate age of all components, date installed (if known)and source of information: Cesspool to pit"B"original to home. Pit"C"added later Were sewage odors detected when arriving at the site? ❑ Yes ® No 28 Stone Horse Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 City(rown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) No septic tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 28 Stone Horse Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 CitylTown 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap.(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a 28 Stone Horse Rd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No D-box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 28 Stone Horse Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit"B" is 6x6 block and dry at this time, cover 1' below grade, equipped with an outlet T Pit"C" is of precast construction, cover 2' below grade, 2-3' stone surround,dry at this time, stain line 2' below inlet invert 28 Stone Horse Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration cesspool to 2 overflows Depth—top of liquid to inlet invert 4' Depth of solids layer 1' Depth of scum layer 0„ Dimensions of cesspool 6x6 Materials of construction block Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool has 1' of effluent in it at this time, equipped wth an outlet T, cover 12" below grade, no adverse conditions Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a 28 Stone Horse Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 28 Stone Horse Rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 IL Assessing As-Built Cards Page 1 of 2 TOWN OF BAMStABLE LOCATION SEWAGE N VILLAGE C ASSESSOR'S MAP&LOT►'}ZO7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACFIY LEACHING FACII.TTY.(type)MCI 12 i-f7ywiu) NO.OF BEDROOMS 'y �� BUILDER OR OWNER �, I�JJ �`rW� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If an wetlands exist within 300 feet of leaching facility) _ S Feet Furnished by is 3S �6 S3Ig1D ,1 http://www.town.bamstable.ma.us/assessing/HMdisplay.asp?mappar=142070&seq=1 5/11/2015 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 28 Stone Horse Rd Property Address Kern Owner's Name Osterville MA 02655 5/7/15 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 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: pate ❑ 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: per elevation of home 28 Stone Horse Rd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form copy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is OSTERVILLE MA 02655 9/24110 required for every page. Cityr town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When A. General Information filling out forms I n on the computer, use only the tab 1. Inspector. key to move your cursor-do not JAMISON A. DESROSIERS use the return Name of Inspector key. .. JAMISON A. DESROSIERS �y Company Name 62 KOMPASS DR. Company Address EYALMOUTH MA 02536 Cityr town State Zip Code (508)444-6420 S113025 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r A0 I s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. V ` 28 STONEHORSE RD OSTERVILLE-03108 Title 5 Official Inspection Fam Subsurface Sewage Disposal m•Page 1 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is OSTERVILLE MA 02655 9/24/10 required for 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with.a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 28 STONEHORSE RD OSTERVILLE•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ distribution box is leveled or replaced ND Explain: r ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within.50 feet of a private water supply well. 28 STONEHORSE RD OSTERVILLE•03108 Title 5 Official tnspedion Forth:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28-STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cont.): ❑ 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 if well water analysis, performed at a DEP certified laboratory, for coliform T s system passes the a y , p ry, bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6°below invert or available volume is less than,%day flow ❑ ® 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. 28 STONEHORSE RD OSTERVILLE•03= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owneirs Name information is OSTERVILLE MA 02655 9/24/10 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"non to each of the following, in addition to the questions in Section D. Yes No ❑ ®; the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate . regional office of the Department. 28 STONEHORSE RD OSTERVILLE•MOB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name k information is OSTERVILLE MA 02655 9/24/10 required for every page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® . Pumping information was provided by the owner, occupant,or Board of Health ❑ ® Were any of the system components pumped out in.the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® 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 ® El 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)] 28 STONEHORSE RD OSTERVILLE-03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M .•'p 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 550 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ' 550 Number of current residents: 0 Does residence have'a garbage grinder? ❑ Yes ® No Is laundry on a-separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd)_ Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 28 STONEHORSE RD OSTERVILLE-0301 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 I Commonwealth of Massachusetts 959 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 28 STONEHORSE RD Property Address ANNE KERN Owner Owners Name information is required for every OSTERVILLE MA 02655 9/24110 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: NONE PROVIDED - Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) - ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ® Other(describe): SYSTEM HAS MAIN CESSPOOL AN 3 OVERFLOWS.2 WITCH ARE PITS Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes Z. No 28 STONEHORSE RD OSTERVILLE•030) Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ®cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age- yeas Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 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 How were dimensions determined? 28 STONEHORSE RD OSTERVILLE•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): 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.): 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)- 28 STONEHORSE RD OSTERVILLE•03108 Title 5 Official Inspection Fonre Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: . gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be.opened)(locate on site plan): . Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No r Alarms in working order: ❑.Yes ❑. No 28 STONEHORSE RD OSTERVILLE•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-6X6 ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number 1-6X6 ❑ 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.): MAIN CESSPOOL GOES TO AN OVERFLOW CESSPOOL WITCH WAS FULL AT TIME OF INSPECTION. OVERFLOW GOES TO A 6X6 PIT WITCH WAS ALSO FULL AT TIME OF INSPECTION.THEN GOES TO LAST 6X6 PIT WITCH WAS EMPTY. STAINLINES WERE AT 2' 28 STONEHORSE RD OSTERv1LLE•03= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 achusetts Commonwealth of Mass Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is required for every OSTERVILLE MA 02655 9/24/10 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 1' Depth of solids layer 4 Depth of scum layer 211 6X6 Dimensions of cesspool Materials of construction BLOCK Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): CESSPOOL WAS FULL AT TIME OF INSPECTION BOTTOM IS AT 9', CESSPOOL APEARS TO BE WORKING PROPERLY. 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.): 28 STONEHORSE RD OSTERVILLE•03108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massadhusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owners Name information is OSTERVILLE MA 02655 9/24/10 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. g3- 53 '6G" 28 STONEHORSE RD OSTERVILLE•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 STONEHORSE RD Property Address ANNE KERN Owner Owner's Name information is OSTERVILLE MA 02655 9/24/10 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water. 12+ P 9 9 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: USGS MAPS } 28 STONEHORSE RD OSTERVILLE•M= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 RONALD J. CADILLAC, PLS, RS, P.C. Professional Land Surveyor&Registered Sanitarian P.O. Box 258, Nest Yarmouth,MA 02673 (508) 775-9700 TRANSMITTAL FORM To: Barnstable Health Agents who review plans Re: P# 12884--28 Stonehorse Road, Osterville--Anne Kern property Date: October 12, 2010 Certified : ❑ No. ❑❑❑❑❑ Fax Enclosed: Message: Please be advised that we have not received payment for sevices on this project and will not be turning in soil evaluation report No. 12884 until we receive payment. Please call with any questions. Thank you. uJ CO _J s-1 m . C�1 cn E _ M N tL- e--i Z C7 3 0 0 F- N' I RONALD J. CADILLAC, PLS, RS, P.C. Professional Land Surveyor&Registered Sanitarian P.O. Box 258, West Yarmouth,MA 02673 (508) 775-9700 TRANSMITTAL FORM To: Barnstable Health Agents who review plans Re: P# 12884--28 Stonehorse Road, Osterville--Anne Kern property Date: October 12, 2010 Certified : ❑ No. ❑❑11110 Fax ❑ Enclosed: Message: Please be advised that we have not received payment for sevices on this project and will not be turning in soil evaluation report No. 12884 until we receive payment. Please call with any questions. Thank you. RONALD J. CADILLAC, PLS, RS, P.C. Professional Land Surveyor&Registered Sanitarian P.O. Box 258, West Yarmouth,MA 02673 (508)775-9700 TRANSMITTAL FORM To: Barnstable Health Agents who review plans Re: P# 12884--28 Stonehorse Road, Osterville--Anne Kern property Date: October 12,2010 Certified : 11 No. 0❑0❑❑ Fax : ❑ Enclosed: Message: Please be advised that we have not received payment for sevices on this project and will not be turning in soil evaluation report No. 12884 until we receive payment. Please call with any questions. Thank you. . r RONALD J. CADILLAC, PLS, RS, P.C. Professional Land Surveyor&Registered Sanitarian P.O. Box 258, West Yarmouth,MA 02673 (508) 775-9700 TRANSMITTAL FORM To: Barnstable Health Agents who review plans Re: P# 12884--28 Stonehorse Road, Osterville--Anne Kern property Date: October 12,2010 Certified : ❑ No. ❑❑❑❑❑ Fax : ❑ Enclosed: Message: Please be advised that-we have not received payment for sevices on this project and will not be turning in soil evaluation report No. 12884 until we receive payment. Please call with any questions. Thank you. ' TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE i ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) fi ize) NO.OF BEDROOMS BUILDER OR OWNER va't �- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet .Edge of Wetland and Leaching Facility(If.any wetlands exist within 300 feet of leaching facility) woo ,` I Feet Furnished by J ) y 0 G • 1 *21q �-S5 LOCATION SEWAGE jPERMIT NO. VILLAGE l A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR . OWNER o DATE.PERMIT ISSUED BATE COMPLIANCE ISSUED e j S£ ; LOCATION SEWAGE E ERMIT NO. VILLAGE 8 � 1 A & B CESSPOOL SERVICE 128 BISHOPS TERRACE HYANNIS MA 02601 BUILDER OR .OWNER y DATE PERMIT ISSUED BATE COMPLIANCE ISSUED , ., r� v � � �.� � � ' r eS9� / 1 I � �� �_�z�� r... -_ J r TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE0 Dili],� ASSESSOR'S MAP & LOT 14-ZO') O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) n ize) NO.OF BEDROOMS � BUILDER OR OWNER - PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching.Facility(If.any wetlands exist within 300 feet of leaching facility) ; j �A Feet Furnished by �3 �- Ig No�A-_.39.,/ Fps.$._.15.00......_ THE COMMONWEALTH OF MASSACHUSETTS =w• BOAR® OF HEALTH .....................T.own...........OF.............Barnstable Alip iration for Bispoii al Works Tonotrnrtinn amit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 28 Stonehorse-Road, Ostervillej MA -02655 z -• -_. ................•-------...------------...........------------------------------.....--- Location-Address or t o. Jeffrey.Sullivan „ „ _ 28 Stonehorse Road, Idseraville, MA 02655 -----------...............................-......................... ...._......._......--•- .. Owner Ad ss W A & B Cesspool-Service „ „ 128 Bishops Terrace, �yannis , MA 02601 Installer Address dType of Building 3 Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...................••___._-___._ _Expansion ttic ( ) Garbage Grinder ( ) �+ Other—T e of Building No. of persons____________________________ Showers — Cafeteria Q, Other fixtures -------------------------------- - w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................ Disposal Trench—No_____________________ Width.................... Total Length............._------ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •---••-•••-•----------------••-••--••---•--••-••••••---•••••••-........••-•••••-••••••-•••••---...••......................................................... 0 Description of Soil............................... and----------------------•------•---•------••-------•-•-••-••--••--•--------- x w UNature of Repairs or Alterations—Answer hen applicable.___ nstallation of a 1,000 gallon pre-cast, stonepackedleach it (overfl -------------------------------------•-•-------------------•-••••-..._..... --- __ -_ p Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL U 5 of the State Sanitary Code— The undersigned fur-,;.Pr agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by the bard of t . r / /d � x"i ne FS Application Approved By-------___•_ _____ /� - ,� =----------.'. Date Application Disapproved for the following reasons----------------•----...._._..-------..-.-•--•---------•-------------------------------------•••••••-••....•-••-- --.....---•----------------------•--------...---•-•------------------•--•--••---------........-•--------------•--------------------------------------..----------------•-.----------------•••••-------•- Permit No.84-••-•-•-••••.......••••--•••--•--•-•-•----._.-.... Issued_.-..-/27/8 •---------------•------Date---... Date No84- THE COMMONWEALTH OF MASSACHUSETTS � BOARD OF HEALTH ............Town----------.OF.............Parlisteul , pphrati,on for UispnaFal Works Tunotrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 28 3-Lonehorse load 0stervill Y., 026 j .._..... .............. � A2 --•--••... ......................................... ----••--••--...-••--•••--.....---•----•-•- ... _---• -- ... ._•-•-- Location-Address or LotJeffrey ;ulli�an 28 Stonehorse road, OrAr avi lle, •A 0265.K __ --------••--••••-- ..........-.....................................................................................Owner _ -PnYZ9GeA e'LYITIIu 1 A �2E01 W .. �c B Ges.� 01 w ry ic:, 12i> Bishops '!f:s a '....... ---•--••-•--•-••----•---•-••••--•----••--•-• P o Y Installer Address Type of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion ttic ( ) Garbage Grinder ( ) a e of Building a Other—T yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 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 ( ) a Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... �. f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................-------------•-- ---,-•-•------•-•-----•-------•--•••-•-----••...---•-•.....-•-•--•••....--•-_....---•--•-•••--••----••--•--••••-•--•-••••.........•••-- Description of Soil SB=nd................. -------•-------._...-- .................................... f U ....••-••-•-----•----------•--------•------•--------•--•----•----•---------•••••••---•-.....••--------••--•-•---•-•••-------•--•--•....--•--••------•-•-•--•---••••••-•-•-.....--•.................•---- UW •-----•----------------------•----------•-----------.....---------------•-•----------•---•--•-----••--------••----------•-------------•-••--•-----•-•- J n'1 Nature of Repairs or Alterations—Answer hen applicable....g�LSta11�_t_ or of a, I,QVU ;melon hyL'-ce t, stone . .......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned fujker agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard of Signe�w . ... . .........................Y:l.... ................................ 1 / Application Approved By---------- __ /2��` ;;5-011 ------------------------•------ Date Application Disapproved for the following reasons................................................................................................................ 1 --------------------•------------•--•---......---------------......------.....------........---------.....-----------------•---------------•-----•--------.............................................. Date ry { l — � 7( �54, y PermitNo. ..................................................... Issued--.--................................................... ; Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 "OST....OF....E8rnstabls. .................................................................... i Trrtifiratr of Tomplitanre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constr cted ( ) or Repaired (X ) by..A-`,_- Cess)ool Serv9.ce. 128.Bishooe_ Terrace, Hyannis, ?:I± 02601 -- ---•--••-•--.----- ------ I 5ller at_28 Stonehorse road Gsterville 11% 02Va - Jeffrey Suaii van, has been installed in accordance with the provisions of T TLE 5 of The State Sanitary Code a!3 cribed in the application for Disposal Works Construction Permit No..__-__._.._ �/ dated............ ...`WW_---..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM VII�L�.��J`�CTION SATISFACTORY. DATE....................................................:.....................•----. Inspector..---- . ...................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD {.,OF HEALTH Tcw n Barnstanle $ 15.00.. ...........................................OF........................ ...............•-•------------..........--•-•-•-••-........ FEF........................ arks T-Fnntrnrttinn amit Permission is hereby granted........... -- --- Cesspool. �exviee ---------------------------------------•----•--• .......... ........ .............. to Co s r%t ( )) or-.,Re agr ( X an Ili vidu Sew s-o* stem atonelzorse ., O ter�r� �e, :A ba ' �e1: re �iil?. van atNo.... ----•--••-•-----•-••--•----••----•-••••-•---...•---•-------...-••••--•--•-•--••--••---------. ••--=--------•------ Street 84 — �d"' 4/`2 7/i,,�i as shown on the application for Disposal Works Construction Permit No...................:. ated.........-_._/..........................._. mil 4/27/84 ------------------------------------------- of Health DATE. k __ ,,,..•�° Y.. T FORM 1255 A. M. SULKIN, INC., BOSTON