HomeMy WebLinkAbout0142 STURBRIDGE DRIVE - Health 142 STURBRIDGE DRIVE, OSTERVILLE
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i
Commonwealth of Massachusetts -
f Title 5 Official Inspection -Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name vy
information is v
required for every Osterville V MA 02655 9-1-16
page. City/Town , State Zip Code Date of Inspection h.a
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.
A. General Information
1. Inspector: v f
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services r
Company Name
P.O. Box 73 A. . r. r
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 16.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes- ,❑ Fails_ -
❑ Needs Further Evalu by the Local Approving Authority,, +t .
` 9-1-16
zy
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
�� VAS
Commonwealth of Massachusetts
r Title 5 Official, Inspection Form '
- I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
w Elaine Breslin
Owner Owner's Name
information is required for every Ostefyille MA 02655 9-1-16
page. A-4 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 is in good working order with no sign of failure.
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 0 4 k;t'
:+ Title 5 Official Inspection -F&M
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments. .
142 Sturbridge Dr r n
Property Address
Elaine Breslin
Owner Owner's Name
information is Osterville # MA 02655 r 9-1-16
required for every
page. City/Town State Zip Code Date of Inspection ,
B. Certification (cont.).
❑ Pump Chamber pumps/alarms not operational. System will pass,with Board of Health approval if
pumps/alarms are repaired:
B) System Conditionally Passes (cont.);
❑ Observation of sewage backup or,break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
r pass inspection if(with approval of Board of Health):
El broken pipe(s) are replaced ` El "❑ N ❑ 'ND (Explain below):
-❑ obstruction is removed' z ., " ' ❑; Y , ❑,N ❑ ND (Explain below):
❑ distribution box is leveled or replaced' ❑ Y ❑ NV ❑ 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):
I
C) Further Evaluation is Required by the Board of Health: ' a • .
❑ 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 inja 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osterville MA 02655 9-1-16
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 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 ,
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or poridirig 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I
Commonwealth of Massachusetts r ;
:fir r Title 5 Official Inspection. Form
�') Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osterville MA 02655 9-1-16 '
page. City/Town,*` 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.'
t' ❑ ® Any portion of.a' cesspool-or,priyy 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- t
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 -
rc system.owner should contact the Board of Health to determine what will b6,
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 "
El ❑ the system is within 200 feet of a tributary to a surface drinking water supply
E 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
Title 5 Official Inspection Form^+
'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v%
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osterville MA 02655 9-1-16
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, 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 afthe 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): 4 Number of bedrooms (actual): 4
i
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
9 fy Title 5 Official Inspection Form
rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
i
�•,;!, 142 Sturbridge Dr # -
Property Address
Elaine Breslin
Owner Owner's Name
information is Osterville MA' 02655 9-1-16`
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information - " . i.
^
Description:
Number of current residents: 0
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? El Yes ® No
Water meter readings, if available (last 2 yearn usage (gpd)): t,• r
Detail:
Sump pump? t-;_, t; ,�• .: ❑ Yes ® No
Last date of occupancy: L, _ Unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
flow Desi n ' based or;310 CMR-15.203 :
g ( ) Gallons per day(gpd)
�t Basis of design flow(seats/persons/sq.ft., etc.): i
Grease trap present? r= .* ,t ❑ 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
=1 f Title 5 Official Inspection Form
;W Subsurface Sewage Disposal System Form Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osterville MA 02655 9-1-16
page. City/Town 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: N/A
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):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
I Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments
� a
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Ostefyille MA 02655 9-1-16
page. City/Town s State Zip Code Date of Inspection
D. System Information (cont.) '.
Approximate age of all components, date installed (if known) and source of information:
1980's
Were sewage odors detected when arriving at the site? T ❑ Yes ® No
Building Sewer(locate on site.plan): '
Depth below grade: . f 30"feet
Material of construction:
❑ cast iron 'Z 40 PVC ❑ other(explain): &
• : ,. .
Distance from private water supply 'well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 24
feet''
I
Material of construction:
® concrete ❑ metal ❑ fiberglass s❑ 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: 1000 gal-
12"
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
:a} f Title 5 Official Inspection. Form `
�r
- Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osteryille MA 02655 f 9-1-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Septic Tank(cont.) s
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
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
15"
How were dimensions determined? Tape
Comments on pumping recommendations inlet and outlet tee or baffle( p p g f e condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank in good condition with baffles installed and no sign of leakage.
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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts ►i
Title 5 Official Inspection For
�W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4_a;1a� 142 Sturbridge Dr
Property Address ;
Elaine Breslin
Owner Owner's Name u
information is re Osterville - MA 02655 9-1-16
required for every
9
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):
f
Depth below grade:
Material of construction:
❑ concrete ❑'metal ❑ fiberglass ❑ polyethylene ❑ other(explain): .
Dimensions: .
Capacity: }
gallons'
Design Flow: . .;. a _ -
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 .
Commonwealth of Massachusetts
a,l f Title 5 official Inspection Form
If,., Subsurface Sewage Disposal System Form Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osterville MA 02655 9-1-16
page. City/Town 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 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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑, Yes- ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts • .
Title 5 Official Inspection Ford ti
Subsurface Sewage Disposal System Form -' Not for Voluntary Assessments -• i
142 Sturbridge Dr
Property Address ,.
Elaine Breslin
Owner Owner's Name
information is required for every Ostefville MA 02655 9-1-16 ,4
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1-1000 gal
❑ 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 podding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection withstain line at 36" below inlet invert.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
�
R' .�A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a%
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is Osterville MA 02655 9-1-16
required for every '
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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
y Commonwealth of Massachusetts
:fir f Title 5 Official, Inspection Form
I.I Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
�F
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is Osterville r.
required for every MA 02655 9-1-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
P'
B-3 3*3
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17'
Commonwealth of Massachusetts
^4 �o Title 5 Official Inspection form
�. Subsurface Sewage Disposal System Form-Not forvVoluntary Assessments
142 Sturbridge Dr .
Property Address
Elaine Breslin
Owner Owner's Name
information is required for every Osterville MA 02655 9-1-16
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: 20'
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)
r
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official -Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Sturbridge Dr
Property Address
Elaine Breslin
Owner Owner's Name
information is Osterville MA 02655 9-1-16
required for every .
page. City/Town State Zip Code Date of Inspection,
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
CERTIFIED SEPTIC SYSTEM REPORT . \
2 44 �
m
tolv
22� )8 A:
LOCATION \ � c»
«
142 STORBRIDGE OR.
OSTERVILLE, MA 02655
MAP 166 PARCEL 083 LOT 45
. PREPARED yOR
. - e.
MR. ANDREW J . WITTER.
FIRST PROPERTY MANAGEMENT
832 MAIN ST.
OSTERVILLE, MA 02655
DUYER
MR. DANIEL BRESLIN
142 STURBRIDGE DR.
OSTERVILLE, MA 02655
PREPARED BY
HILLIARD HILLER
P.O. BOX 250
CENTERVILLE, MA 02632
508-778-1472
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE HINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIAN1 F. Yt ELD
TRUD1'COXE
Governor
Sccrrtt-,
ARGEO PAUL CELLUCCI DAVID B.STRL'HS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissionrr
PART A
CERTIFICATION
Property address: 57T//'4e/O4; O,0 r P./ ds4Gl441410 Address of Owner: Ale��AIZ111 IT,
Date of Inspection: 31y�x (If different) `i:C'tT QXoc' n' .ts/�,e�/IGt�iCar
Name of Inspector: //, 111a� gj�- 4501'-w S�
I am a DEP approved system.inspector pursuant to Section 15.340 of Title 5 (310 CMR 1S.000)
Company Name:_
Mailing Address:' U '�X Sa :. G.Eti11i�U/lei,[ A-1,1 4>0)e_42
Telephone Number: S -774-,//?,X
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,-inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
�,<Plsses
Conditionally Passes
Feeds Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: c �� Date: 3 8 J-
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall subm t
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owne,
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION' SUA1n1\Rl': Check B, C, or D:
AI SYSTEM PASSES:
4.1 nave not found any information which indicates Ihat the system violates any of the failure criteria as defined in 310 C.MR 15.303
nny 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
I'
Com p fiance (auached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; o:
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan'.
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
I as approved by the Board of Health.
(r•vi..0 o�/]5/57) P.9. 1 of 10
DEP on the World Wide Web: hnp:/Avww.magnet.state.ma.usrdep
t.-) Printed on Recycled Paper
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -;,61z;'e". e-ec
Owner: fJ;e/�GEw J- Gci/ !Ei(
Date of Inspection: j//y-
B) SYSTEM CONDITIONALLY PASSES (continu d)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, ealed or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describ observations:
broken ipe(s) are replaced
obstru ion is removed
distrib tion box is levelled or replaced
The system required pu ping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspeoion.if(with appr val of the Board of Health):
Oro en pipe(s) are replaced
ob truction is.removed
Q. FURTHER EVALUATION IS REQU RED BY THE BOARD OF HEALTH:
Conditions exist which.requ re further evaluation by the-Board of Health in order to determine if the system is failing to protect the
public health, safety and th environment.
1) SYSTEM WILL PASS UNL SS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT HE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pi y 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 U 'LESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUN TIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The systen has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tri'ouiary t a surface water supply.
The syste i has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The sysi-,n has a septic tank and soil--absorption system and the SAS is within 50 feet of a private water supply well.
The syst m has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private eater supply well,.unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the we I is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less th n 5 ppm. method used to determine distance (approximation not valid).
3) OTHER
I
(rwi��d, 0+/25/97) Pogo 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /5',?
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate eit,,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans
for this determination is identified below. Th Board of Health should be contacted to determine what will be necessary to correcl
the failure.
Yes No
Backup of sewage into facility or sy em component due to an overloaded or clogged SAS or cesspool.
Discharge orponding of effluent to he surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
,Static.liquid,level in,the.distributio box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth.in.cesspool is less th n 6".below,i.nverf or available volume is less than 1/2 day flow.
Required pumping more than 4 ti es in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorptio System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or priv is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or pri is within a Zone I of a public well.
Any portion of a cesspool or pri is within 50 feet of a private water supply well.
Any portion of a cesspool or pri y is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysi . If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliforrn bacteria, volatile organ c compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large syst ms in:addition to the criteria above:
The system serves a facility with a desig flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the enviro ment because one or more of the following conditions exist:
Yes No
the system is within 400 feet f 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 nit ogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shal bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 011R 5.00 and 6.00. Ple,se consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: i
Owner: �¢,litiQ/�G� J. Gam✓/ls�
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
_4.� _ None of the 'system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection.. .
As built plans.have been,.obtain ed and examined. Note if they are not available with N/A.
t� The,facility or dwelling was inspected.for. signs.of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was.inspected for signs of breakout.
✓ _ All system components,*7cluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.:302(3)(b)�
• 6
(reviled O4/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: IV,' S>Z/iL/,---/.nG,c D�4 �T,t✓1v1G�.E
Owner: `f f/O�Q�6-1
Dale of Inspection: 3A/f,
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents: (,,✓�/'/�e.4
Garbage grinder (yes or no):�Y�
Laundry connected to system (yes or
Seasonal use (yes or no): ,Zei
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):_ Lt?
Last date of occupancy_'_ %
C 0 M M E R C I A U I N USTRIAL;
Type of establish ent:
Design flow: gallons/day s/day .
Grease trap pres t: (yes or no)
Industrial Waste olding Tank present: (yes or no)
Industrial
wa to discharged to the Title 5 system: (yes or no)
Water meter re ings, if available:
Last date of oc upancy:__
OTHER: (Des vibe) _
Last date of o cupancy:__
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes or no),e!�
If yes, volume pumped: gallons
Reason for pumping:
TYPE O� SYSTEM
P/ Septic tank/ soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, artach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected ",hen arriving at the site: (yes or no) _
(revised 04/25/97) - Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construct n: _ cast iron _ 40 PVC _ other (explain)
Distance from priv e water supply well or suction line
Diameter
Comments: (cond tion of joints; venting, evidence of leakage, etc.)
SEPTIC TANK:_v
(locate on site.plan) .:
Depth below grade:
Material of construction: concrete _metal Fiberglass Polyethylene _other(explain)
If tank is metal, list age Is,age-confirmed by Certificate of Compliance _(Yes/No)
Dimensions: �� X a Q® `7 Oe?e
Sludge depth: /O"
Distance from top of sludge to bottom of outlet tee or baffle: �G
Scum thickness: 6 _ 414-1a
Distance from top o(sc- rrr to top of outlets t e or baffle:
Distance from ba:'Q= el sc-�tto onom SI outlet tee or baffle: 23,
How dimensions were determined: Ili
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
ntegrin, evidence of leakage, etc.) JXXA/—, T�.GS 'k�
7Z,i5 /W� UW KAII—e- S
G, i
GREASE TRAP:
(locate on site pl n)
Depth below gr de:__
Material of con ,ruction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thicknes
Distance (ton top of scum to top of outlet tee or baffle:
Distance fron bonom of scum to bonom of outlet tee or baffle:
Date of last umping:
Comments:
(recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, e idence of leakage, etc.)
(ravie d 04/25/57) Page 6 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: / .4'aX4,"l J• Ga//1T EiC
Date of Inspection: 3/y
TIGHT OR HOLDING T NK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construed n: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm.in working order Yes; _ No
Date of previo pumpfrig:
Comments:
(condition of let tee, condition of alarm and,float switches,-etc.)
DISTRIBUTION BOX:_ L/Uii �/�S S.ti✓���D �,vA �45, f' J'' GvS �o��r✓.O
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working o der: (Yes or No)
Alarms in working rder (Yes or No)
Comments:
(note condition of ump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 01 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Iy-1 5 '�
i
Owner:
Date of Inspection: 3�y/yx
SOIL ABSORPTION SYSTEM (SAS):,
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:• /
leaching chambers, number._
leaching galleries, number:.
leaching trenches, number,length
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system: .
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation, etc.)
�xG i°rT sax'x 7112- A,,17,>��l ry �yG Thy /dlT .Oro
,2 of
/�s�"7t�G,�r /-�f-xT T✓�y�' i�r fir �s oo�,�.�
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:_
inflow (cesspool must be pu ped as part of inspection)
Comments:
(note condition of soil, signs of hydr ulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:__
Comments:
(note condition of soil, signs of by raulic failure, level of ponding, condition of vegetation, etc.)
(reviaod 04/25/57) Pig• 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1,Y l
Owner:
Date of Inspection: jy
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
13�c"o
I
0
(revised 01/25/97) Pag• 9 of 10
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: !y,2 STU�/ iiJG.� 0„e; j�.lv�GGc
Owner:
Date of Inspection:
Depth to Groundwater
eet
Please indicate all the methods used to determine High Groundwater Elevation;
Obtained from Design Plans on record
Observation of Site (Abutting properly, observation hole, basement sump etc.)
Determine it from local conditions
Check with local.Board of.health
Check FErvMA neaps
Check pumping records
Check local excavators, installers
V Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
i
Tr e-;!-
57 Q,Piy�v,;¢�c`- ��o�� T/�L ll�a9Tt:C T is J9j c.r'��T,�.✓
y '
7r5'G vS6S' 1.,.�sc'.`',�ci ion/ I•`� 3.C
(rsvio•d 04/25/97) P.g• 10 of 10
1 'TOWN OFBARNSTABLE.
vu ."SFsson�S:, s�
1N5TA�'�EId.'S NAB��'�QNE T�YO '`
SIEFrl C 7I'Ai°TI CAPA7.
CITY
a ',,.PERll�ITl�A'I'E .. C(�1�/�i'°i~.IR►S�](
SepAraeiotttia3 8c:tj►�eert ii7a; ;
MaXlmumd ustetl Feel
G►auuifwatet Talals90 tl�c Bnttorn pTLeaching Nacility
l
1�lvaieCa�:r Supi+ly VJail �c@ i.eac.hing l�acilatyOf
tauy; ial9s cxist irec8
att aitcs ac writhin�Qp Beet of tsnctuq�g faciiity)
Ectur 6 wle " d and]..eat lntt i~aciiiey 4 y.wetlands exist :
svifi�itiQQ fce f teapling
J.�a CK
4
a o
3 �
A-l 03'8
A3- 3C B:3 - Y33" .
TOWN OF BARNSTABLE
I.oCAJ11ON 6&ZC..9"&,C SEWAGE
VILLAGE ASSESSOR'S MAP & LOT
AME&PHONE NO. la, A1ZU,,fX
SEPTIC TANK CAPACITY 10A:::;e 6/fL-.
LEACHING FACILITY: (type) 101J7- (size) 4:!—�5tZ
NO.OF BEDROOMS
$ -OR OWNER ' f,►.y�,�lZliJ J, G��Tl�%11
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility .0'¢ 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 faci ' Feet
Furnished by L 3& g S
C31�c
i
f�1V-Al>X
7D
I