The URL can be used to link to this page

Home My WebLink About0006 STURBRIDGE DRIVE - Health 6 Sturbridge Road —0 A= 1 2R µ: 66 :Y a P -e b 9 4 Y F n a ° � c , m a ° " ° " rs a e . , ° w µ f' e " v ° x , , n n n °n ° , ° 4 V. Ea o t. x ^ o a F y P ® Iwo lk Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address /4►N1 Owner Owners Name information is Q� 11 . � required for every OS 4er✓I ll Q 111 page. City/Town State Zip Code Date of I specg n 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, use only the tab 1. Inspector: �V/!► key to move your , Inspector- cursor-do not use the return key. Name of Inspector ICI Company Name o oZ 8P Company Address �GsfGta� /y 0d 61/4 -t City/Town � — � State Zip Code Telephone Nu er c 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 �10MR 15.000). The system: Passes ❑ Conditionally Passes ❑ 4rbrils ❑ Needs Further Evaluation by the Local Approving Authority 'r a _n /6 *Inspectorture Date The system inspector shall submit a copy of this inspection report to the Apprpving Authority and of Health or DEP)within.30 days of completing this inspection. If the system is a share€If'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. t5iris-11/10 Title 5 Offidaf lnspedion Form:Subsurface Semp Disposal System-Page 1 of 17 I i a - Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C64 V 4" ), Property Address Owner Owner's Name information is OS4- / e r v/ Ile- oo 6 6/a/w required for every page City/Town State Zip Code Date Ins erdion B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) Syste 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: 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. n * 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•11/10 Title 5 Official Inspection Form:Subsurface Sevage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name Lo information is -krv/Ile / 1 Od�55 required for every 1,/�Y �_L/` (� page. Cityrrown State Zip Code Date 6f Insp6ction B. Certification (cunt.) 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): 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 ❑ 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. I. 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•1 v10 Title 5 Official Inspection Form:Subsurface Sevsge Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name //information is Qo?6J:� bXV/ required for every page. Cityrrown State Zip Code Date of Inspdction B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic.tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ 0/ 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 gg 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 tsrns•ivio - ritle 5 OlfidW Inspection Forth:subsurface Sewage Disposer System•Pape 4 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, s 1/� ��r C/✓1 C<i-�i �f� Property Address Owner Owners Name /� v information is //�Jap,V1 Ile- page.required for every l/ /'C City/Town State Zip Code Date Of Insp ction B. Certification (cont.) Yes No ❑ E 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. ❑ 2--- 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.] ❑ [0,-*-- 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 CM 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, {I 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5irrs•11110 ' Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary' Assessments Property Address Owner Owner's Name information is required for every �/�7�✓Vt Ile le page. City/Town State Zip Code Date#t Insp lion C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No Vd' ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 21_� Were any of the system components pumped out in the previous two weeks? L�" ❑ Has the system received normal flows in the previous two week period? El ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Q/❑ Were as built plans of the system obtained and examined? (If they were not /- available note as N/A) LN' ❑ Was the facility or dwelling inspected for signs of sewage back up? LN' ❑ Was the site inspected for signs of break out? L� ❑ Were all system components, excluding'the SAS, located on site? L�' ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the bafflesior tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ��❑ Was the facility owner(and occupants ifadifferent 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Numberof bedrooms(actual) DESIGN flow based on 310 CMR 15.203(for example: 110 4pd x#of bedrooms): t5ins•11/10 Tft 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a Property Address Owner Owner's Name information is ✓� required for every page. City/Town State Zip Code Date of/nspec6on D. System Information Description: / / 1S 01 c soo G�/40� • . d Number of current residents: a Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes EI�No Laundry system inspected? El Yes [ 96 Seasonal use? ❑ Yes R No Water meter readings, if available(last 2 years usage(gpd)j: Detail: Sump pump? ❑ Yes 9--go Last date of occupancy: C11G4✓1-ew Date Commerciallindustrial 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 Industrialwaste,holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name /��information is �! 1 1 Q6 3.5 6 required for every page. Citylrown State Zip Code Date of lnspbctiory D. System Information (cont.) Last date of occupancy/use: Date ` Other(describe below): en -G erallnformat�on , Pumping Records: Q W"' Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy em: 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): t51ns•11l10 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 J 4Gt✓4rI c'c,.Q D✓' Property Address Owner Owner's Name /Je information is e✓ required for every - Ile— page. City/Town State Zip Code Date f I ns6ection D. System Information (cont.) Approximate age of all components, date installed (ifk�n wn) and source of information: r Oct — l� O t.✓�c� Were sewage odors detected when arriving at the site? ❑ Yes 0—fq6-___ Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ` ast iron PVC ❑other :ex lain ( P ) 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 Znal of struction: ncrete ❑ metal fiberglass El pol eth lene y y El other(explain) J If tank is metal, list age: years IS age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes [INo Dimensions: /`✓ 1,(2 Sludge depth: C —� t5ins•11/10 Title 5 Official inspection Form:subsurface Sewage Disposet System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address d</ Owner Owner's Name /g information is required for every Vd�S 7�lr'` l� /� /� 6-5,r page: Citylrown State Zip Code Date 6f Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top g of sludge to bottom of outlet tee or b affle Scum thickness Distance from top of scum to top of outlet tee or baffle �i 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.): G N S /✓� 00 61,cal�qh. &0 Lem�s . Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness r 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-11/10 Title 5 Official Inspection Forth:Subsurface e �9 Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address i/ Owner O Owners Name information is required for every w ✓V, Ile /e page. Cityrrown State Zip Code Date f I lion D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: - Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-page 11 o117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not Not for Voluntary Assessments Property Address IZO Owner Owners Name information is OS-Jey y /e r ��required for every // 14/ page. Cityfrown State Zip Code Date of In pectin D. System Information (cunt.) 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.): ,/o f 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If.SAS not located, explain why: - ,`t t5ins•11/10 ' i Tdle 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Owner Owners Name !/ information is v / Op C� required for every i/ � � /�-/ _ (� page. CitylTown State Zip Code Date ofnspe ion D. Systemrc� rmaltion (cont.) Type. d 61-c-,14o (Lo✓ne C14r-141S r1 a ❑ leaching pits number: ❑ 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.): S, 0 1e Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Me 5 Official Inspection Form:Subsurface e e ��8 f System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System System Fo -Not for Voluntary Assessments T� . ✓ � 6 Property Address Owner Owner's Name // information is �v! G !�required for every _�%/� page. CitylTown State Zip Code Date of Inspecfion D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a _ r Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Irrspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IF Subsurface Sewage Disposal S tem Form - Not for Voluntary Assessments � � Property Address 6 Owner Owners Name information O� ✓mil /� required for every page. City/Town State Zip Code Date of(nspecti6n D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately V, a . Ll Q�- a 7 t5irts-11/10 - Title 5 olrrdal lnspection Form!Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name / 6/ information is required for every 6 page. Cityrrown State Zip Code Date of I pection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar -f-- ❑ Shallow wells / -b Estimated depth to high ground water: - ` feet , i 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 El Observed site (abutting property/observation hole within 150 feet of SAS) with local B and 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: V Iti-c Before filing this Inspection Report, please see Report Completeness Checklist on next page. f5ins•11/10 Title 5 Official Inspection forth:Subsurface Sevage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners Name information is /7�1ev�! Z/6�,/z required for every (� / d page. Cityrrown State Zip Code Date of nspe6tion E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked inspection Summary D (System Failure Criteria Applicable to All Systems)completed [YSystem Information=Estimated depth to high groundwater i. Sketch of Sewage Disposal System either drawn on page 15,or,attached in separate file t5ins•11/10 Title 5 OfficW nsoection Form:Subsurface Sewage Disposal System•pays 17 0!17 COMMONWEALTH OF MASSACHUSETTS 'z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6 Sturbridge Road Osterville MA 02655 Owner's Name: Marion Harrington Owner's Address: Same s� F 7 3� 7 Date of Inspection: May 18,2005 Job#05-147 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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` Uttttp� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ��.• N.OF _X Passes •'9CyG T Conditionally Passes = RIC :m Needs Further Evaluation by the Local Approving Authority = M. ON co Fa' : Inspector's Signature: ' Date: 5/18/05SIN 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. Notes and Comments: Observed only small puddles of standing water in leaching chambers.System not designed for use with garbage grinder, recommend removing grinder or pumping tank annually and installing effluent filter. ****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 5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMk 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined Y,N,ND in the for the following statements. If"not determined" lease ( ) g P 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 distribution box is leveled or replaced ND explain: 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: Tit1P G rno—tinn 17^r 4/1 ci100n 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 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: z _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for 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: Title i Tncnartinn Rnrm All VInnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 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 %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 _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.l 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 the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Titla i Inenantinn Gnrrn All snnnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 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 . Y P g , _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)J Titla G Tncnartinn Anrm A/i G/7nnn 5 'L Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—31,000 gal.2004—35,000 gal.=90 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Never been pumped Source of information: Owner Was system pumped as part of the inspection(yes or no): 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 10/16/01 Were sewage odors detected when arriving at the site(yes or no): No Titles C inenartinn i7nrm Ali,;iinnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM— T FOR L NO O VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 16" Materials of construction:—X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5' long x 5.8'wide—1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 11" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of.leakage,etc.): Tees intact and liquid level at bottom of outlet pipe.Observed traces of solids in outlet tee(from garbage grinder)recommend pumping tank. GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titla C Tnonantinn Rnrm 611 vinnn 7 f : Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No high stains or solids present.Liquid level at outlet invert. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Titles f Tnenontinn Fnrm��i sionnn 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: —X_leaching chambers,number: Two 500 gal drywells. 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.): Observed a small amount of standing water with no sidewall stains in chambers CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): TitJP S incnprttnn Rnrm 0;11 ai)nnn 9 Y Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 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. Sturbridge Road i� Water service 214 A Garage 1 2 3 A-1 =1I' A-2=22' A-3=27' B-1 =25' B-2=27' B-3=37' ' Titla Tnonontinn Rnrm Krl cnnnn 10 l V Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 Sturbridge Road,Osterville Owner: Marion Harrington Date of Inspection: May 18,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.5 and topo map shows property above el.50. T41a f Tncnantinn Fnrm rui;moon 11 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. •A Business Certificate ONLY'REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take.the completed form to the Town Clerk's Office,, 1st FL., 367 Main Street, Hyannis, MA 02601' (Town Hall) and get the Business Certificate that is required by law. Fill in please: Date:23 E APPLICANT'S NAME: �-�- �kAR. YOUR HOME ADDRESS: ( y-i"ti is y�,.i t�C I !�i C' k.-,v,'lI e Al �., C'�? e�.S BUSINESS TELEPHONE Z# 5� r / HOME TELELPHONE #: �66 ; ( f ` NAME OF CORPORATI.ON.- l�l'fi'Mc. /vl r!':b , '.Ll. C �, NAME OF."NEW,BUSINESS ��T; .N-��v,�' �1 r.c.1.�z.� ' l:C TYPE OF BUSINESSto ►! ' I;�2 t. 1 iyA S IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS � �-�i x � �,i-Ll�i�1 Ie ;. M 4-`SSMAP/PARCEL NUMBER 66-0 (Assessing) When starting a new business there. are several things 'you must do to be in compliance with the rules and regulations of the Town of Barnstable. This.form,is`to assist you in obtaining the information,you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. 8 Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed.of any permit requirements that pertain to this type of business: Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has b in formed of the permit requirements that pertain to this type of business. L` ar 1 Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) . This individual has been informed of the licensing requirements that pertain to this type of business. . Authorized Signature** COMMENTS: TOWN OF BARNSTABLE LOCATION j� lJ/LI�G %O,4/J SEWAGE VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME '& PHONE NO. A & B CANCO 775-6264 I .SEPTIC TANK CAPACITY 7 LEACHING-FA CILITY:(type 2 0 /,Q (k'CCS (size) 3--l'I 2� NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER- BUILDER OR OWNER �� N DATE PERMIT ISSUED: Co (Sj Ir) I. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �( NtwPvRT �.�►r�c:' 1` Gg2AC Q . �V _o—p e c TOWN OF BARNSTABLE LOCATION lie J ite6 SEWAGE # VILLAGE / I ASSESSOR'S MAP & LOT r &PHONE NO. KL,•� f 75 E' SEPTIC TANK CAPACITY 0 LEACHING FACILITY: (type) Ae4o (size) go NO. OF BEDROOMS FOR OWNER >9 ago iL 79A/U( i�t' 11/u /C i U i/� PERMITDATE: 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) Feet Furnished by t3torbrt Ck ro 27 Z �