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Home My WebLink About0033 SUNSET LANE - Health 33.Sunset Lane Osterville A= 117-123 TOWN OF B.ARNSTABLE ' 7 ` Vol" LOCATION3-1 ►�: 'X1 SEWAGE # VILLAG � E ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. � PigB, s �( SEPTIC TANKiCAPACITY 4.� LEACHING FACILITY:(type) ( (size) Y NO. OF BEDROOMS PRIVATE.WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No //—' ,!.-. - �. ,�� `� 4 i / ` r • �w s t, ASSESSORS MAP NO: PARCEL NO:' No.............. ...... Fizz...Q�.....a............... THE COMMONWEALTH OF MASSACHUSETTS ,ABOARD OF HEALTH ......................................................... Appliration for BWVona1 Works Tnnstrnr#iun ranti# Application is hereby made for a Permit to Construct ( ) or Repair (L-�_an Individual 'Sewage Disposal System at: ' ------------------------•--••------- - - ... .-. .. Location.Address .or Lot No. .......--•--------•--•--------••-•-•--•••••• ........................... ................................................._..... Owner Address a ----••..... -�� !-0_F......gns ------------------------•-•-•--• .t! ,4`"�'' Fay t Instalier Address UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms......../.................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures _ _____ __________________ 0. W Design Flow........ _._.. _..gallons per person per day. Total daily flow....................................•_._:__gallons. 1:.4 Septic Tank—Liquid capacityloYa...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 ( ) aPercolation Test Results Performed by.......................................................................... Date----------------.... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ------------------------------- ---•----- •-•--- •------------------ ---------------------------------- •----------------------------- •....... .-------------- ..... 0 Description of Soil........................................................................................................................................................................ x V VW •---••----------------------------••---•------•-------•------------•-------•---•-•---••-••--------------•-------------------------•----------••--•-•---------------•--•-- Nature of paaiirs or Alterations—Answer wh n applicable._.-.fl'__gr4cl -------�?r_—A_____________�______----._-----__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii LE ;of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed•........ �9....... ��-r---.._..... -------------�---e------�----------- Application Approved By......... -- -a...................................... ------ -/�DD----(••A•..... Date Application Disapproved for the f ollo ' g reasons:----•-------------------------------------------------------•-----------------------..----•-------------------- ..--•-••••----------------------------•--••--•------------••----•------------------------...------------•---•------------------------•-----•-•---•--------------------•--•----•-------------•--......._. 2 ` Date Permit No.............J. !....• - Issued_ Date No................ ..... f 2� Fizz.. : . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 (��-'�--------------- OF.-... 7 (. .-.......-.................................................. Appliratinn for Disposal Works Tono rurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or. Repair ('r-`-) an Individual Sewage Disposal System at 4 '�-1�- - Location-Address or Lot No. ...................... .:4_................................................. .........._-._......-'----.�.fl.✓...r-_._...--------..........----._...._.....--'--..._......--- Owner Address a �l f✓ / rF%.. C?•'c.5.%.. r`. .....c:r �/✓'_f..___!. "��....."``'f -------------'----'-"-•---......-•--•- Insta,ier Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms____`X__________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of ersons____________________________ Showers a YP g --------------------------•- P ( )•-- Cafeteria ( ) Otherfixtures -------•--•-------------------------'-----------------•-••••••--•---•••----•-----•••-••--••-••••--•-••-•••-••••'•-- _......•__. W Design Flow....._--`�...�_' ' ....... ------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit}�.'.i��,:_____gallons Length................ Width................ Diameter______________- Depth................ Disposal Trench—NTo_ ____________________ 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........................................ ,a Test Pit No. -1..........•-----minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix --•---------------------------•----...-----•--._...------------.....--------•--..........._..------.._..__.....---'--...__...-------•-•..__..._-------------- 0 Description of Soil----------------------------------------------------------------'-'-------...---------------•-----------------'-----------------------------------•-•------'-•'--•••-- U .................................................--..................................................................................................................................................... W x Nature of a airs or Alterations—Answer w en a--•licabl ---4 �' e22 i--------- %��^••--••-•--••. •-•-• .................... L ----------1 -------------- ----------•---- Agreement: The undersigned agrees to install the aforedescribed Individual S6vhke�Disposal System in accordance with. the provisions of TI T LE 5 of the State Sanitary Code—The.unders fined further agrees not to place the system in operation until a Certificate of Compliance has been issued.by the-board of health. . Signed__`. - -f_r=` �=- c/4d� ' ' .. f _.... ...,,. =3- �� Application Approved BY x A !'' ��........:.................::"--------. ................................'•....... I f{ Date Application Disapproved for the follo ' g reasons:......... ''___E_'..:?____ _____________________________________________ •-••'•-•••••-••--•-_..._.....-•'••----•-•'---'•-•----•--•--'-----•--•••-...-'-•••'•--•--'...--------"'--•-••-•-•-•-••-'...-------•--•-•-----•-•'•-•'••-----------•••••--••...------••••-•--•--....-•--- �L Date PermitNo...--•--'-'-'J---------•------------------------------- Issued.------...--------------------.._..----------------..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........319.N.......O F........� 5..:............................................ (Irrfifiratr of fauntpltanrr THIS IS4P CERTIFY, r hat the Inci:v du 'I Sewage s osal System constructed ( ) or Repaired ( } by------------------- .1�: (,�:. ----------- - ►i ----------------------------------------------•-------------•--...-------------- at. . - ---------------------------•--------------------------------------------- has been installed in accordance with the provisions of TT- o-- The State Sanitary C de a des��yyr ed in the application for Disposal Works Construction Permit No._ -. ........... dated_-.... .:"__�_-___�1 _________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... ..`.. . ..' _? ___ Inspector..... _. -✓ ............................. ,✓ t� �� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. NO ..... .. FEE..................... Disposal lVorkii Tn r#rurtion rrntit Permission is hereby granted___.M1f3/!.. -____......_.cfl!'` ^( ............................................... ................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst ?T --33-- - � �� - �.!'�1.............� x' 1t l'"""�t'...._... ; as shown on the application for Disposal Works Construction Permit No _ Date,_.__ __........... _ __. : . - _...: �� ................ .....--== ____________________ Board of Health. ". DATE............. ....... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS F TOWN OF BARNSTABLE 7 LOCATIONS 3 SEWAGE # Q VILLAGE ; tZQ�.�.1\ ASSESSOR'S MAP 6z LOT INSTALLER'S NAME dz PHONE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) X(Q NO. OF BEDROOMS"TPRIVATE WELL OR PUBLIC. WATER BUILDER OR OWNER . i DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: :— VARIANCE GRANTED: Yes No t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: �key to move your h . cursor-do not Carmen Shay use the return Name of Inspector key. Shay Environmental Services Inc. --� Company Name .�, C'o tab .. P.O. Box 1576 -- Company AddressCD ».; Ir r� Mashpee MA .w„� 02649 Cityrrown State Zip Code 508-294-7498" 3080 Telephone Number License Number ryi B. Certification 6. 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: Z Passes ❑ Conditionally Passes t ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/12/13 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owners Name information is required for every Osterville MA 02655 4/12/13 page. 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: 0 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: This System Services a portion of the House and the Cottage and consists of a block cesspool (4'x6') with and overflow precast leach pit(4'x4'deep with 4' of stone around) Both were empty with no discernable stain line. System not in use for 5 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. 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): r t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owners Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts = v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville - MA 02655 4/12/13 page. Citylrown 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 ❑ ❑x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 21 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged.SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow - t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ o 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of apublic well ❑ 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 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. ❑ 0 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 4 ❑ 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Sunset Lane Property Address Estate of Mary Butler Owner owner's Name information is required for every Osterville MA 02655 4/12/13 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 ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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? ❑ 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? • ❑ 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? ❑ 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: ❑x ❑ Existing information. For example, a plan at the Board of Health. 0 El 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): - 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Cesspool with overflow leach pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes n No Laundry system inspected? ❑ Yes Z No Seasonal use? Z Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail Sump pump? ❑ Yes'Z No Last date of occupancy: 5 years-ago Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Canons 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-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 M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CurrentDate Other(describe below): General Information Pumping Records: Source of information: none on file Was system pumped as part of the inspection? ❑ Yes 0 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 ❑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)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•11110 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 wM e y 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Cesspool Unknown, Leach Pit is 1985 per permit Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron ❑x 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaking pipes or improper venting Septic Tank (locate on site plan): Depth below grade: feet Material of construction: Z concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments wM 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Cisterville MA 02655 4/12/13 page. CitylTown 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: feet Material of construction: ❑concrete El metal ❑fiberglass El 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete. El 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33_Sunset Lane_ Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/town State Zip Code a 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 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Leach Pit found, No Liquid in pit and no discernable stain line noted due to long term non use t5ins-11/10 Title 5 Official Inspection Form: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 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 1-6'x 4'w/Wstone ❑ 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.): No evidence.of.hydraulic_failure, Leach pit was emty with no discernable stain line. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1-4'x6'cement block Depth—top of liquid to inlet invert No liquid present Depth of solids layer No solids present Depth of scum layer no scum present Dimensions of cesspool 4'x6' Materials of construction cement block Indication of groundwater inflow ❑ Yes 0 No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulicfiailure, level of ponding, condition of vegetation, etc.): Empty with no discernable stain line 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 Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments �M .' 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Citylrown 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: 0 hand-sketch in the area below ❑ drawing attached separately 'A }» t 3 .- -- !94 a',,r t5ins-11110 Title 5 Official Inspection 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 4M ' 33 Sunset Lane Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope 0 Surface water 0 Check cellar ❑ Shallow wells 20 feet Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x Observed site (abutting property/observation hole within 150 feet of SAS) 0 Checked with local Board of Health -explain: i Reviewed groundwater maps on file at town hall ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in this neighborhood. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 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 33 Sunset Lane Property Address Estate of Mary Butler Owner Owners Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked 0 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System—Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection 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 A. General Information filling out forms —t on the computer, .�-+ , , C� use only the tab 1. Inspector: �I- V =r key to move your lJ cursor-do not Carmen Shay ^� use the return ' ke . Name of Inspector ..,� Y Shay Environmental Services, Inc. "ICI Company Name c.:*7 P.O. Box 1576 Company Address r= s7e Mashpee MA 02649 City/Town State Zip Code 508-294-7498 3080 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ❑x Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving.Authority {� 4/12/13 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 DER 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-11/10 Title 5 Official Inspection Fo .SuUsurtace Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityfrown 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: This System Services a portion of the kitchen and laundry and one bath of the main house and consists of a block cesspool (6'x8')with and overflow block pit(8'x8'deep) Both were empty with no discernable stain line. System not in use for 5 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. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is - required for every Osterville MA 02655 4/12/13 page. City/rown State Zip Code Date of Inspection B. Certification (cont.) 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 orreplaced ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown 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: 0 D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of-the following for all inspections: Yes No ❑ O 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 ❑ 21 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-11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Z Required pumping more than 4 times in the.last.year_NOTdue 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. El 0 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. ❑ 0 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-4 ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x 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. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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 ❑x ❑ 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? 21 ❑ Has the system received normal flows in the previous two week period? 0 Have large volumes of water been introduced to the system recently or as part of this inspection? ❑x ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) El ❑ 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? 4 0 ❑ 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: ❑x ❑ 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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information .Residential Flow Conditions: 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Primary Cesspool with overflow cesspool. Number of current residents: 0 Does residence have a garbage grinder? El Yes ❑x No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes 0 No Seasonaluse? Z Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail Sump pump? ❑ Yes 0 No Last date of occupancy: 5y_ears ago 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: 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 �M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: none on file Was system pumped as part of the inspection? ❑ Yes 0 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 ❑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) 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•11/10 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 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: El cast iron 040 PVC El other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaking pipes or improper venting Septic Tank (locate on site plan): Depth below grade: feet. Material of construction: Dconcrete El metal ❑fiberglass El 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Citylrown 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: feet Material of construction: ❑concrete ❑metal ❑fiberglass El polyethylene El 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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.): 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 El polyethylene ❑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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Overflow cesspools found. No discernable stain line on either the primary or overflow cesspool. t5ins•11/10 Title 5 Official Inspection Form: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 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Cisterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑x overflow cesspool number: primary is 6'x8' - 2ndary is 8 x 8 ❑ 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.): No evidence of hydraulic failure, Cesspools were empty with no discernable stain line. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1-6'x8'& 1-8'x8' Depth—top of liquid to inlet invert No liquid present Depth of solids layer No solids present Depth of scum layer no scum present Dimensions of cesspool see above Materials of construction cement block Indication of groundwater inflow ❑ Yes ❑x No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown 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.): Empty with no discernable stain line .. 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.): i t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4112/13 page. Cityrrown 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: 0 hand-sketch in the area below ❑ drawing attached separately lot 1*z -. - ° �'x5' 'tort 0'"", to 1`� tL r 3 — 64 0 41� t5ins-11/10 Title 5 Official Inspection 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 G1 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope ❑x Surface water 0 Check cellar ❑ Shallow wells 20-feet Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x Observed site (abutting property/observation hole within 150 feet of SAS) ❑x Checked with local Board of Health-explain: Reviewed maps s on file at town hall 9 p ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in this neighborhood. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 33 Sunset Lane-System#2 Property Address Estate of Mary Butler Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityfrown 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 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17