HomeMy WebLinkAbout0069 TANGLEWOOD DRIVE - Health 69 TANGLEWOOD DRIVE, OSTERVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form Not for Voluntary
g p y u tary Assessments
69 Tanglewood Drive
tJ' -
Property Address
Craig Bryant "Pl
Owner Owner's Name a
information is Osterville t✓ Ma 02655 11-18-19 �
required for every
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 filling out forms A. Inspector Information SAr PP 93
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130 ,
Company Address
VQ Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system: ,
1. ❑■ Passes t
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
�m- �,��,e.W.
Brett Hickey e�1�� � .�,��s 11-18-19
pale:NII0.1 t.t214,0710 USW
Inspector's Signature Date
F
s 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
r Please note: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.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11A8-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) '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:
The system was in working order at the time of inspection.
2) Systemi 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):
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official- Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code' Date of Inspection
C. Inspection Summary (cont.) T
2) System Conditionally Passes (cont.): '
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 El 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):
r Y
. i
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
im Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
I
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. 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.
c. Other:
k
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
❑ due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
r
Commonwealth of Massachusetts r
' Title 5 Official Inspection Form ry
!' Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments .
69 Tanglewood Drive �e
Property Address
Craig Bryant -
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.), ,
i .
Yes No ,
E] Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ El Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
r X Required pumping more than 4 times in the last year NOT due to clogged or
1 `' ❑ obstructed pipe(s). Number of times pumped:
❑ [D Any portion of the SAS, cesspool or privy is below high ground water elevation.
C lEj Any portion of cesspool or privy is within 100 feet of a surface water supply or
i
El tributary to a surface water supply.
El Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well. .
❑ 0 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.]
y The system is a cesspool,serving a facility with a design flow of 2000 gpd-
El 0 10,000 gpd.
❑: El ` The system4ails. 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
j necessary to correct the failure.
} 5) Large Systems: To be considered a large system the system must serve a facility with a
f 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 CA -
-
dlt Yes No
❑ - ❑ the system is within 400 feet of a surface drinking water supply
x ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply .
I' R the system is located in a nitrogen sensitive area(Interim Wellhead Protection'
ti El El Area—IWPA)or a mapped Zone II of a public water supply well -
t5insp.doc`•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Z
-k
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owners Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ 0 Pumping information was provided by the owner, occupant, or Board of Health
❑ ❑ Were any of the system components pumped out in the previous two weeks?
0 ❑ Has the system received normal flows in the previous two week period?
❑ O Have large volumes of water been introduced to the system recently or as part of
this inspection?
o ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ 0 Was the facility or dwelling inspected for signs of sewage back up?
Q ❑ Was the site inspected for signs of break out?
0 ❑ -Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ 0 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:
E] ❑ Existing information. For example, a plan at the Board of Health.
❑ 0 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
�u—
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
f ,
1. Residential Flow Conditions:
3 ' 3
Number of bedrooms(design): Number of bedrooms(actual):
330/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of.bedrooms):
Description:
F
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes RI No
information in this report.)
Laundry system inspected? ❑ Yes E No
Seasonal use? ❑ Yes (E No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
'2019- 14,000gallons 2018- 16,000gall6ns
Sump pump? El Yes ❑■ No
{ ' Last date of occupancy: Daterent
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
- ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
V�
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Owner- date of last pump is unknown
{
Was system pumped as part of the inspection? ❑ Yes H No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
69 Tanglewood Drive y
v
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State - Zip Code Date of Inspection
+ D. System Information (cont.)
s
4. 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.
0 Other(describe):
Tank and Pit }
Approximate age of all components, date installed (if known)and source of information:
Newer pit added (1985) to existing tank (1976)
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
61
Depth below grade: feet
Material of construction:
❑cast iron ❑■ 40 PVC ❑other(explain):
Town water
Distance from private water supply well or suction line: feet
x
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
r
a
Commonwealth of Massachusetts r
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u=
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owner's Name
information is Cisterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
5'
Depth below grade: feet
Material of construction:
0 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
1000gallons
Dimensions:
10If
Sludge depth:
2611
Distance from top of sludge to bottom of outlet tee or baffle
311
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
1511
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
m
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
'? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
69 Tanglewood Drive
L
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
h
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related-to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction: '
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
. a
Dimensions: _.
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
� s
a1 , ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
NA
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
n Title 5 Official Inspection Formy
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments..
l ,
69 Tanglewood Drive
v Property Address
Craig Bryant '
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State .Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan): k
Pumps in working order: ❑ Yes, ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
i
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
i
t
I .
Type:
Elleaching pits number: 1 ) 6W' pit
❑ leaching chambers number:
❑ leaching galleries number:
❑' " ' leaching trenches number, length:
❑ leaching fields, number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Pit was dry when viewed.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert,
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
i
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive ~-
,u� Property Address _
Craig Bryant `
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
. . NA • ,
Materials of construction: !
Dimensions ,
Depth of solids
I Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i -
i
' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
. r
j •
Commonwealth of Massachusetts
Title '5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
V
Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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:
n hand-sketch in the area below
❑ drawing attached separately
Garage
l
A
1
Al-14' 2
A2.1W
A3-28'
BI-276"
62.21'
B3.16' 3
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive -
u
Property Address
Craig Bryant
Owner Owner's Name `
information is Osterville Ma' 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
F ❑■ Check Slope
❑■ Surface water
❑■ Check cellar
❑■ Shallow wells
' -Estimated depth to high ground water: No GW @ 15'
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
0 Observed site (abutting property/observation hole within 150 feet of SAS)
l
❑ Checked with local Board of Health -explain: r
❑ Checked with local excavators, installers -(attach documentation)
1 '
Q Accessed USGS database -explain: -
see below
You must describe how you established the high ground water elevation:
Topo maps were used to determine high groundwater. Ground water in area is greater
than 15' below grade. Bottom of SAS is greater than 4' above ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood Drive
v Property Address
Craig Bryant
Owner Owner's Name
information is Osterville Ma 02655 11-18-19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete'all applicable sections of this form inclusive of:
❑■ A.'Inspector Information: Complete all fields in this section.
�■ B. 'Certification: Signed& Dated and 1, 2, 3, or 4 checked
❑■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
�■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
4
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1
Commonwealth of Massachusetts f 0-7J
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Name
information is Owner's
required for every Osterville MA 02655 6/26/2014
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 filling out forms A. General Information
on the computer,
use only the tab 1 Inspector:
key to move your
cursor- not
use the return
urn Michael DiBuono
key. Name of Inspector
DiBuono Sewer and Drain
Company Name
8 John's Path
Company Address
South Yarmouth MA
City/Town 02664
State Zip Code
508-354-9587 S113522
Telephone Number License Number
I
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15..340 of
Title 5(310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-26-2014
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•3113
Title 5 Official Inspection Form: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 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Cityrrown 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:
® II 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:
The system contains a 1000 Gallon Concrete septic tank. And a concrete leach pit. Both the tank and
pit are in good condition.With no signs of deacy or overloading. Pit has little water in it and the level
is approximately 3ft below the invert pipe.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is Osterville MA 02655 6/26/2014
required for every
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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3/13 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 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving.a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should 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
El ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
f
Subsurface Sewage Disposal System°°Form Not for Voluntary Assessments
w 69 Tan lewood dr
Property Address
Beth Morrill
Owner Owner's Name 2014
information is Osterville MA 02655 6/261
-- --- Date Inspection
required for every City(rown State Zip Code
page.
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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
obtained and examined? (If they were not
® El Were as built plans of the system
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
... 2
Number of bedrooms (design): 2 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
220
r
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
t5ins-3113 "
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is Osterville MA 02655 6/26/2014
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system contains a 1000 Gallon Concrete septic tank.And a concrete leach pit. Both the tank and
pit are in good condition. With no signs of deacy or overloading. Pit has little water in it and the level
is approximately 3ft below the invert pipe.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage 2012 85,000
g ( y g (gpd)): 2013 73„000
Detail:
Total GPD over two years 213 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 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 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Currently occupied
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Home owner every two years
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):
No dbox
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is Osteryille MA 02655 6/26/2014
required for every
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System is Approximately 30+years old and functioning properly.
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 62"s
feet
Material of construction:
® cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
No signs of Decay or leaking. Baffles are in place. Scum level Is minimal
Septic Tank(locate on site plan):
Depth below grade: 4ft
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth:
2"s
t5ins•3/13 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
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 26"s
Scum thickness
2"s
Distance from top of scum to top of outlet tee or baffle s
Distance from bottom of scum to bottom of outlet tee or baffle 18"s
How were dimensions determined? Tape measure, Sludge Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No signs of Decay or leaking. Bafflers are in place. Scum level Is minimal. No pumping
recommendation at this time.
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•3/13 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 , 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Cityfrown 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.):
No signs of Decay or leaking. Baffles are in place. Scum level Is minimal
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
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.):
I
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert NA
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
No pump chamber
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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 signs of carry over, Ponding
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
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.):
No signs of hydrualic failure or ponding
i
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 Forth:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. Cityfrown 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
i
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
AsBuilt: Page 1 of 1
LOCQT ON 4 5EW&C,E. PERMIT MO.
.V ILL AGE
IMSTQLLER•5 U&NIE ADDRESS
BUILDER 6 Q L�MF- 4,00 -55
DATE PERNAIT 15SUED =-- _—
f
D ATE COMPLI&MCE ISSUED
L 6-�y� STvn = �rFo �1r�
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=121079&seq=1 6/25/2014
Commonwealth of Massachusetts
Title 5 Official Inspection F 0rm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is required for every Osterville MA 02655 6/26/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
� I
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+ FT
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 topographics in this area and local well readings. No ground water at 20 + ft
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked topographics in this area and local well readings. No ground water at 20 +ft
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 69 Tanglewood dr
Property Address
Beth Morrill
Owner Owner's Name
information is Osterville MA 02655 6/26/2014
required for every
page. Cityrrown 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
J
J THE COMMONWEALTH OF MA HUSETTS �� ,
BOAR® OF HEALTH -�
:..1 s�.. .0. ..............o F.....�'�ct r.. t.S.ra 1 ...........................................
Appliration for Dispasal Works Tonstrnrthin ranfit
Application is hereby made for a Permit to Construct ( ) or Repair (Gan Individual Sewage Disposal
System at: JJ
.......C.,P_...._,T -
.....Rd................ .............
_ P... ..'.......
ation-�Address or Lot No.
% r-- -.... ._®.�....�' .................................... ....................... ............ . 1)0
..............................
0wner Address
.......�.� .T�� Ak.1 XV-J.5...------ --•-----......•..---... �.t-P---r.:�1.a 1. ................................
Installer Address
d Type of Building Size Lot...........................Sq. feet
aDwelling—No. of Bedrooms..._.................................Expansion Attic ( ) Garbage Grinder ( )
a, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures --------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.._...;..___.__..__- Deptfi below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground:'water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•••------•-••.......---••--•-•-------•---•---•-•-•----------•--•-------•-•-•••...............................•............
--------------
-.....
-..........
••--
0 Description of Soil..-----... �'t -----------•-•--••----•-----------------------------------------
V ---------•------------------------------------------------ .... ---------.....---..........-•---.._..-----------------•----•......•---.....-------•••••--
------------------------------------------------•--------------------------------------•-•----- -------- . ................................................... ---
V Nature of R pairs or Alteration Answer when applicable____�. �a1__ .........2._.________- -----
Agreemeut l ?'74
The undersigned agrees to install the aforedescribed Individual Sewage Disposa ystem in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be s e y the rd of health.
Signe
•----------------
i�h�:� ....
Date
Application Approved By----•-----.�•--••�'c••..............................•-----•---------------------•-----------•-
Application Disapproved for the following reasons:.........................................I...............................
......................................
..........................•-------------......---•-•------......-•-- ....................................•--
Date
Permit No.......<2• ........ ....1..•........... Issued-....... C-••-•-• - .1
- --- _. �
Not t F�$. . ._. ..`'..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF I—¢I�EA�tLTH
..+ fi..� ---------- OF... IUY'.h. l t`'t 1: :.................................•--...-----
Appliratiun for Disposal Works Tonstrurtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
cation I Address .or Lot No. -
.......-6X!. .... ...............` "------- _......... .....................................
�° .+► Owner , [��
i�" . ------ =�= ='� L' d"° ��=
Installer Address
UType of Building Size Lot............................Sq. feet
1-1 Dwelling—No. of Bedrooms___.............__...................Expansion Attic ( ) Garbage Grinder ( )
�`4 Other—Type of Building No. of ersons____________________________ Showers
YP g ---------------•----------•- P ( ) — Cafeteria ( )
' d Other fixtures --------•--••---------------------------------••-•--•----••-•_•-••.--------••---•--•-•-••••------•------._...--- ------
W Design Flow............................................gallons per person per day. Total daily flow.....................:........................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_______.________ Depth................
x Disposal Trench—No.____________________ Width......._............ Total Length...._............... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----
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 ••••-•-••--••--•--••••--••-•••--••..................•••-------•.....--------•--....._•-•-•--•-•-•---.........................................................
O Description of Soil..........
._..•
V .....................................................�� _.....-•-----------.......................
• ---------------•---•-•-••---•----•••••••-----------•-----_--••...................
W
x Nature ofe airs or Alterations Answer when a licable t
U P s¢. PP --- �G"G..7 `s ---�
............. -- --- �-------- e •- --- ,(
AgreemVY': q
The undersigned agrees to install the aforedescribed Individual Sewage Disposal"System in accordance with
the provisions of TITLE 5 of the State Sanitary Code= The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b nai su f y the and of health. _
; . - /Sign � ryDa�teA/
Application Approved BY ----- ---------------- ------ _______
Date
Application Disapproved for the following reasons: :_:.'.`_._.....----•---------------•-••------•-----------•----------------•----=-•------
......................................••-------••----•--•._....---•---•--••--•-...•-----••-•--••---•._._..:......._..-•-•-••-•--•-•-•••-----•------•-----•-••-•---=•--•-----•••••---------••----------
(� r ,% Date
Permit No....._.. - �� =1 1 ------------_ Issued.: .�..�.PL......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................OF...
......t •f�tb 1 .................._...............__.._..._...
Trrtifiratr of Totnplianrr -00
T CERT Y, That the Individual Sewage Disposal System constructed ( ) or Repaired
by... ..................................................
�r+°•P'
nstaller ,, f j
1141.
has been installed in acc ance with the provisions of TIT,,11Ejof The State Sanitary Code as desc ib d in the
application for Disposal Works Construction Permit No.-f>_________________f............... dated_....4' _.___..__.__ ---�15..---.•...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C STRUED AS . GU ANTE THAT THE
SYSTEM WILL FU CTIO S ISFACTORY.
DATE..................4..... .. ................................... Inspector--••- ......................
.. I
.� THE COMMONWEALTH OF MASSACHUSETTS
BOAR 011111,,OzF�;+,EA LTH
.1.1...... .....,OF.... � - r. .f,� �'Ja
No.................. FEE. ...... ........
Disposal Vorkp TonstrudWn Vantit
Permission is hereby granted--- ' - ............... k.. -�- •-----••--•......................................................
to Construct ( ) or�Re air an Indi idual S.w e Disposal Syst j ;
at No-_------- s _s t►e ?_slpe_4"-?_t---r--C------------------------------•--...........
PP P street � , �'l ,
as shown on the application for Disposal Works Construction Permit No..................... Dated..... � W
j ��
Board
rd lth........................................_
DATE....-
`Q�f of F��lth
= ................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
LOCATION SEWAGE PERMIT NO.
�l
VILLAGE
` INSTALLER'S N, ME i ADDRESS
d U I L D E R� OR OWNNEN
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED '
Al )t;17
G` o,6
ys�
Y
l
L7OCATIOKI ' t SEW&CtE PERMIT UO.
- - 0
- - - - /yUvl e- - -
IWSTALLERS 1J&ME ADDRESS
BUILDER 'S Q &ME 4t, ADDRESS %DUo 6,
DATE PERMIT ISSUED
D ATE COKAPLI &MICE ISSUED : — — —
'T
I D O v 64L
y
i ��
f �1� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEAL H
..... .... .... OF........ ..............
Appliration -fur Miipoiial Works Tomtrurtiun Vrrnift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
_2.......... ,.► 1 - ......................... ,., ------------- --- -------------------
Location- ^res�s/, p or�ot No.
l
`:.).! ��1_-. .-:------------------ Pvl-_�"'\ �:-. '"e'.......•. -�•6�i�y
Owryer Ades
.�t.l..�`:..... .... . -�°"-s---A---------- .16aA44._ +��f...........---------------------
---------------------
Installer Address
Q Type of Buildi � Size Lot n� -...;�. ----Sq. feet
DwellingV No.'of Bedrooms.7--------------------------------------Expansion Attic ( } Garbage Grinder (190
aOther—Type of Building ... .--.. _.-- No. of persons............................ Showers ( I ) — Cafeteria ( )'
QOther fixtures ------------------------------------ ----_------------------------------------------------------------------------------------------------------
W Design Flow........ C+� ---------------------------gallons per person per day. Total daily flow..........2—.d�-.-_.-__-----....gallons.
94 Septic Tank-Liquid capacity............gallons Length---------------- Width................ Diameter---------.------ Depth------..--------
xDisposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below ' let...__.._-_.. Total leaching area.--.-_--------_--sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) !� �G/ 7— 7
aPercolation Test Results Performed by.......................................................................... Date....._----...._.--.._...-----._..-......
a Test Pit No. 1-------- ------minutes per inch Depth of "lest Pit-------------------- Depth to ground water.--.------.-------------
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-.-.-.--.------..--..
Ix -------------- - -- ---- . .................................. . •--------........
--
O Description of Soil--- i Q �- --- -
--= . --
W .r
UNature of Repairs or Alterations—Answer when applicable......................:.._.--.............._-.-....._--.-......------------.__.:----....._...
.•--------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 heal h:
Sl tom------ . . -- • --------- ----•-•... ------------•---• •-- ................................
Zate
Application Approved BY. �/ ------ -- ----- .. 7 -76
Date
Application Disapproved for the following reasons: -----------------------------------------------------------------•-•-----------------
-------------------------------------•-- ----------------------------------------------------------------....--------------------------------------------------------------------------------------------
Date
PermitNo..............................................---------- Issued-_------------------- .................................
Date
No.. FizE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL �H
/. .� ..... ..OF................................................ ..:.............
Appliration -for Uiivoiitt1 lVarkii Tomitrurtion Vrru it
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
3-•- ---•----•. a.....................•--....--•-• •-•••-----.-----------.-- ................................VA I
.......... ....-----•-----------------------.....--------
Location- .--tress or"Lot No.
Owner Addjess
l -'G S
Installer Address
Q Type of Building' Size Lot----- feet
U
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( Garbage Grinder (19b
p-, Other—Type of Building __.�.°��:�,.____ No. of persons............................ Showers ( /) — Cafeteria ( )
4a Other fixtures ----•-------•--.----•--..-----
d ----------------•----•--•-•---•----------------------•-•---
W Design Flow---------S_..........................gallons per person per day. Total daily flow__________�.U.31�'__..................gallons.
.W Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter__._-...__.__-_ Depth----------------
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. fI.
Seepage Pit No--------------------- Diameter-___-______-..---.-- Depth below inlet_____..__.... Total leaching area_._--_._-----___-sq. ft.
Z Other Distribution box ( ) Dosing tank -7-- 9 - 76
aPercolation Test Results Performed by..---- -------------------------------------------------------------- Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water._._.____-_.---_--._-
" (fXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_--. --______-___----.
^ -------•-•-•---------I----------------•--•- ................................. ------•--------••--- -- •-
Description of Soil U
J
w
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------..........------------------------..-__._..__---_-.----
---•------••------- ---•-------------------------••-- ............................................................___---------------------------------------------------------------•----•-------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 heal h.
"z ?-
Application Approved By.�!Z_ t. lg-9reasons:
. ........................... Date
Application Disapproved for the following ------------- --------------------------------•----------------------------------------Date..-------•----
•-•--•----•--••-------•-•---•-----------•-•-••------•---------------•--•-•------••••---•-•-•••---•---••--•-•----•-••--•--•--------------•--•-------------------------------------------•...---•-•---••-
Date
PermitNo......................................................... Issued....................... ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ........OF............ .................................
(1:11rrtifiratr of from hattrr
THIS S _ CERTIFY, hat the Individual Sewage Disposal System constructed ( or Repaired ( )
by---t......�'; y- ---- :
In tal r
has been installed in accordance with the provisions of Ar c e XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. _. ......... -., .......... dated..-___?'_-__- ---7:-----:.�--------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------�-----------7.Z...!:Z- ....................... Inspector---
—
THE COMMONWEALTH OF MASSACH TS
BOARD OF HEALTH
3� h � -r.. OF..-...... / �-- - ..........
NO ....
FEE---•-•-------.........
�i>n�o�tt1 ' rk,� �on�t�trti�aat �rrutit
Permission is reby granted-------- -1'---' •--•-- -------- 1 ----�--------------------------------------------------------------
to Cons o �ct ( ) R it ( ) aVIjp� ividual Se ge Disposal System
t Street 7 ry 7`
as shown on the application for Disposal Works Construction Per ' o.____.... ._; D�t d________..'..............................
f Health
are
DATE--------------------------------------------------------------------------------
7--------------
`\\ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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