HomeMy WebLinkAbout0119 TANGLEWOOD DRIVE - Health 119 TANGLEWOOD DR., OSTERVILLI
TOWN OF B STABLE V
LOCATION obr SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS 'nwcb Cn
BUILDER OR OWNER �'I 7/06
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts �� �
Title 5 Official Insp a on Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Y Osterville MA 02655 May 20 2015
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 formsA. General Information
on the computer,
use only the tab 1 Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector t= i! z� —
key. r ' €•m z fi r° w
David B. Mason
Company Name ,
4 Glacier Path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
.-Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
May 20, 2015
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.
V J
t5ins-3/13 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 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all-of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or inr310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The observations noted in this report represent the condition of the system only on this date of
inspection at 7:30AM and the information contained herein does not guarantee the continued
operation of the system. Change in occupancy can result in differing water use resulting in failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
I
t5ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven,distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osteryille MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within'a Zone 1 of a public well.
❑ ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner owner's Name
information is 'Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the'previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
.® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example,
a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( Y 9 (gpd))�
Detail
2015; 72,000 gallons and 2014; 59,000 gallons. Note; one meter for property
J
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
i
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 7 of 17
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
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:
1992
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: 1
fleet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private.water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® 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:
1000 Typical
Sludge depth: 2„
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20 2015
required for every Y
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' 47"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Scour 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.):
Effluent level with outlet invert.
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
r
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.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20 2015
required for every Y
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 effluent level with outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No evidence of solids carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order.' ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located; explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
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.):
6 foot pit. Approx 2 feet of standing effluent in the leaching pit. Evidence of effluent being a foot
higher.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osteryille MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
P .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar.
El Shallow wells
Estimated depth to high ground water: 18'
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:
Groundwater Contour Map
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater Contour Map
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Tanglewood Drive
Property Address
Nicholas Gatzke
Owner Owner's Name
information is Osterville MA 02655 May 20, 2015
required for every _Y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 1 of 1
TOWN OC����,5/TABLE
LOCATIONJ[Ct _I SEWAGE M
VILLAGE ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACM
LEACHING FACII.M;(type) (size)
NO.OF B EDROOMS �
BUILDER OR-OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
MaximumAdjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility. (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by.
s
gCAL
r�k
A4 r,
s
AC ;
• D b � � 30
1
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=121082&seq=1 5/25/2015
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. Owner Information - Map/Block/Lot: 121 /082/-Use Code: 1010
Owner
Map/Block/Lot GLS MARGATZKE,NICHOLAS G DR& 121 /082/
Owner Name as of AMY L Property Address
111115 119 TANGLEWOOD DRIVE 119 TANGLEWOOD DRIVE
OSTERVILLE, MA. 02655
Co-Owner Name Village: Osterville
Town Sewer At Address: No
GIS Zoning Value: RC
. Assessed Values 2015- Map/Block/Lot: 121 /082/- Use Code: 1010-
2015 Appraised Value 2015 Assessed Value Past Comparisons
Building $ 159,800 $ 159,800 Year Total Assessed
Value: Value
Extra $ 38,200 $ 38,200 2014 - $ 337,700
Features: 2013 - $ 337,700
Outbuildings: $ 5,500 $ 5,500 2012 - $ 378,700
2011 - $ 378,600
Land Value: $ 134,200 $ 134,200 2010 - $ 372,700
2009 - $ 356,200
2008 -$ 373,800
2015 Totals $337,700 $337,700 2007 - $406,400
Residential Exemption Received= $87,192
. Tax Information 2015 -Map/Block/Lot: 121 /082/-Use Code: 1010
Taxes
C.O.M.M. FD Tax $ 523.44
(Residential)
Community Preservation Act $ 69.89
Tax
Town Tax (Residential) $
2,329.72 Fiscal Year 2015 TAX RATES HERE
$
2,923.05
. Sales History -Map/Block/Lot: 121 /082/-Use Code: 1010
History:
Owner: Sale Date Book/Page: Sale Price:
http://www.townofbamstable.us/Assessing/printl5.asp?ap=0&searchparcel=121082 5/25/2015
Print Page Page 2 of 3
GATZKE,NICHOLAS G DR& AMY L 2010-07-12 C191914 $320000
MARKOSKI, KEITH R& MEGAN L 2000-11-01 C159596 $295000
GREENE,JOHN S & MARILYN N 1991-06-19 C123655 $45000
LEBEL, JOHN S 1982-09-08 C89575 $4000
. Photos 121 /082/-Use Code: 1010
. Sketches-Map/Block/Lot: 121 /082/- Use Code: 1010
t' f
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e —
As Built Cards:Click card#to view: Card 41
• Constructions Details- Map/Block/Lot: 121 /082/- Use Code: 1010
Building Details Land
Building value $ 159,800 Bedrooms 3 Bedrooms USE CODE 1010
Replacement Cost $177,603 Bathrooms 2 Full+ 1 H Lot Size (Acres) 0.41
Model Residential Total Rooms 6 Rooms Appraised Value $ 134
Style Cape Cod Heat Fuel Gas Assessed Value $ 134
Grade Average Heat Type Hot Water
Year Built -1992 AC Type None
Effective depreciation 10 Interior Floors CarpetHardwood
Stories 1 1/2 Stories Interior Walls Drywall
Living Area sq/ft 1,976 Exterior Walls Wood Shingle
Gross Area sq/ft 4,340 Roof Structure Gable/Hip
http://www.townofbamstable.us/Assessing/printl5.asp?ap=0&searchparcel=121082 5/25/2015
i
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Roof Cover Asph/F GIs/Cmp
. Outbuildings & Extra Features- Map/Block/Lot: 121 -
b /082/ Use Code: 1010 �
Code Description Units/SQ ft Appraised Value Assessed Value
GAR Attached Garage 280 $ 8,600 $ 8,600
PATI Patio-Average 144 $ 900 $ 900
FOP Open Porch-roof- 156 $ 5,400 $ 5,400
ceiling
BMT Basement- 1092 $22,400 $ 22,400
Unfinished
WDCK Wood Decking 310 $400 $ 4,600
w/railings
BGAR . Bsmt Garage 1 $ 1,800 $ 1,800
. Sketch Legend
Property Sketch Legend
1132N Barn-any 2nd story area FPC Open Porch Concrete Floor REF Reference Only
BAS First Floor, Living Area FTS Third Story Living Area(Finished) SOL Solarium
BMT Basement Area-(Unfinished) -FUS- Second Story-Living.Area(Finished)- SP-E Pool Enclosure.
BRN Barn GAR Garage TQS Three Quarters Story(Finish(
CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished)
CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished)
FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished)
FCP Carport KEN Kennel UTQ Three Quarters Story(Unfinis
FEP Enclosed Porch MZ1 Mezzanine, Unfinished UUA Unfinished Utility Attic
FHS Half Story(Finished) PRG Pergola UUS Full Upper 2nd Story(Unfinisi
FOP Open or Screened in Porch PRT Portico WDK Wood Deck
PTO Patio
http://www.towriofbamstable.us/Assessing/printl5.asp?ap=0&searchparcel=121082 5/25/2015
RECEIVED
S E P 2 2 2000
COMMONWEALTH OF MASACHUSETTS TOWN'F BARNSTABLE
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS HEALTH DEPT.
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor x. Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02655 L31
Name of Owner MARLYN GREENE
Address of Owner: 119 TANGLEWOOD DR OSTERVILLE,MA 02666
Date of Inspection: 9/7/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of T►U6 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 608-664-6813 FAX 608-664-7270
F -
CERTIFICATION STATEMENT "
I certify that 1 have personalty inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.;The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation Py the Local Approving Authority
Fails IV
Inspector's Signature: Date:9/11100
The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable;and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined In Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES'TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
MENU ` 1
SEP 2 2 2000
V,
TOWN oF BAR41STABa
RMTH DEPT. ,
revised 9/2/98 Page 1 of 1111 4 j
';3 f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02665 L31
Name of Owner MARLYN GREENE
Date of Inspection: 9/7100 '
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nfa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,
whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfiltration,or tank failure is imminent.The
system will pass inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health.
n(a Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will.pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced u _
_obstruction Is removed
_distribution box Is levelled or replaced
Wit The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if
(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
.t
revised 9/2/98 - Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
i
CERTIFICATION(continued)
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02655 L31
Name of Owner MARLYN GREENE
Date of Inspection: 9/7/00
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require furttie�evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy Is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank,and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance n/A(approximation not valid).
3) OTHER
n/a
r
. 4 ,
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t r PART A
CERTIFICATION(continued)
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02655 L31
Name of Owner MARLYN GREENE
Date of Inspection: 917/00 .
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
_ X Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
- X Liquid depth in cesspool Is less than 6"below invert or available volume is less than 1%2 day flow,
- X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a.
- X Any portion of the Soil Absorption`System,cesspool or privy is below the high groundwater elevation. -
X Any portion of a 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 I of a public well.
- X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
3
- 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 460 feet ofal surface,drinking water supply
X the system is within 200 feet of a'tributary to a surface drinking water supply
X the system Is located in a nitrogensensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information. i
revised 9/2/98' V Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02655 L31
Name of Owner: MARLYN GREENE
Date of Inspection: 9/7100
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: r
Yes No `
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been introduced into the system recently or as part of this Inspection.
X As bui'It plans have been obtained and examined.Note If they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.-
The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
f
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of
construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C Is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with Information on the proper maintenance of SubSurfaca Disposal
Systems.
revised 9/2/98 Page 5 of 1.1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
: PART C
SYSTEM INFORMATION
Property Address: 119 TANGLEWOOD,DR OSTERVILLE, MA 02665 L31
Name of Owner MARLYN GREENE
Date of Inspection: 917/00
Ft
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):n/a
Total DESIGN flow: 330 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO ,
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COM M ERCIAL/INDUSTRIAL
Type of establishment: n/a {
Design flow: n/a gpd(Based on 15.203),
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a t^
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):YES
If yes,volume pumped 1000 gallons
Reason for pumping: MAINTENANCE
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1996
Sewage odors detected when arrlving at the site,(yes or no) NO
revised 9/2198 Page 6 of 11
. i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02655 L31
Name of Owner MARLYN GREENE .
Date of Inspection: 9/7100
BUILDING SEWER:X
(Locate on site plan) <
Depth below grade: 18"
Material of construction: _ cast iron X 40 Pvc other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
i;
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: nla
Dimensions: 1000G L 8'6"H 6'7"W 4'10
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,evidence of leakage,
etc.) .t�", -
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
GREASE TRAP:
(locate on site plan).
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:Na
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a.
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nla
,t +
ra e
revised 9/2198 Page 7 of 11
• 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 TANGLEWOOD DR OSTERVILLE MA 02655 L31
P Y
Name of Owner MARLYN GREENE
Date of Inspection: 9/7/00 '
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan) _
Depth below grade; n/a '
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other ,
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons h
Design flow: n/a gallonstday
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a +
DISTRIBUTION BOX:X t
(locate on site plan) .
Depth of liquid level above outlet invert: n/a ,
Comments: '
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.)
n/a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ' 119 TANGLEWOOD DR OSTERMLE, MA 02655 L31
Name of Owner MARLYN GREENE
Date of Inspection: 917/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a'
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a `
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: nla
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT SHOWS NO SIGNS OF FAILURE.THE PIT HAD V OF
WATER IN IT.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. nla
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure;aevel of ponding,condition of vegetation,etc.)
n/a s
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 TANGLLWOOD DR OSTERVILLE, MA 02655 L31
Name of Owner MARLYN GREENE
Date of Inspection: 917/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks.
locate all wells within 100'(Locate where public water supply comes into house)
F
C
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-ate
rE,
AA ha
AV
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revised 9/2198 Page 10 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
e
Property Address: 119 TANGLEWOOD DR OSTERVILLE, MA 02666 L31
Name of Owner MARLYN GREENE
Date of Inspection: 9l7/00 .
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.).
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
r
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-12+FEET j
revised 9/2198 c Page 11 of 11
m pp
No .� .•3 Fss............._.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH APMOVEQ
Appliration for Dwposal Workii Toustrnrttnn
Application is hereby made for a Permit to Construct (%4 or Repair ( ) an Individual Sewage Disposal
System at:
...TAJV..4 Lt_?.W.Q06. l.l— v --------------------------------
Location-Address o No.
Owner Address
W
Installer Address
Type of Building a• Size Lot.�_ .....Sq. t
Dwelling—No. of Bedrooms....................................................................Expansion Attic ( Garbage Grinder C�
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtur
W Design Flow............... ......... ...................gallons per person per day. Total daily flow__._.......?...................gallons.
WSeptic Tank—Liquid capacity.1 gallons Length_&-Ce.-_- Width.-qfn10__ Diameter------ ------ Depth_ -. )..
x Disposal Trench—No..................... Width____...._._._.._... Total Length.................... Total leaching area._._._.ti .........sq. ft.
Seepage Pit No...____I---.---__ .. Diameter......I-�.-__----•. De h below inlet.................... Total leaching area. ....sq. ft.
Z Other Distribution box ( � Dosin tank
'~ Percolation Test Results Performed by.... +w' _ ?Q_. '1�-V1 ____..__�1_`..� ... ....
`4 Test Pit No. I___4Z-----minutes er inch Depth of Test Pit------Q Depth to ground water__
44 Test Pit No. 2---4�-....minutes per inch Depth of Test Pit-__--�0....... Depth to ground water_______________•-----_ .
a ••------------------••-•---•• .................. ............. - -------
Descri Description of Soil a".. .... !. 1 .4: C ......P NIP------ -
----------� °�•-------� 1 :Z.:= V a�� r c�:_. e 1k111_(
W ••-•••••----............................................................................................................................................................................................
U Nature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been ' sued b the b rd of health.
Signed .........
......................................
Dare
Application Approved B ------ -- -- -------------------- _..-...-- --
-------------------------------------------
Date
Application Disapproved for the following reasons- -------------------------------------V----..............---- -- ------ ---- -- --....---- -----------------
.............................................................. .--- ............................ -- -- --. .-- -------------------------------------------------- -------------------- .................D-a ce- ..............
Permit No. .�.... ................. Issued --------- ..."'.... ""'�
Date
No.!=== a-=• / Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--�U. .
Appliratinn for Dispnnttl Workii Tunitrnr#inn ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
......1-A k;C�r .�Nc c i->_:� >.... ...t ...................................................- t c e a..................................
Location Address or•L No
Owner Address
W
Installer Address
QType of Building Size Lot.. CX)P......Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attie ( Cy Garbage Grinder
Other—T e of Building No. of persons............................ Showers — Cafeteria
dOther fiixtu�res ..----------•-•--•••---••----••- o
WDesign Flow.....................%....................gallons per person per day. Total daily flow..............._......._....._ ....._......gallons.
WSeptic Tank—Liquid capacity.1(<f .gallons Length 23_!�?_... Width.: - 0__ Diameter................ Depth.:!!�-_D.
x Disposal Trench—No. .................... Width ....... Total Length.................... Total leaching area....................sq. ft.
e•a
Seepage Pit No.___-.-I............. Diameter....._I-._--_-_.___- Depth below inlet_._................. Total leaching area.G.-....�....sq. ft.
Z Other Distribution box (�t :'a Dosing tank ( _
'" Percolation Test Results Performed by... �Lf)_._--..--• 5-mvV 4!a ..7V �1: �_3 S
Test Pit No. 1.._��----- inutes per inch Depth of Test Pit -_�........... Depth to ground water •?_c_St sl�' :-
44 Test Pit No. 2...r..z-....minutes per inch Depth of Test Pit____�7 ....... Depth to ground water.-*
ater........................
O Description of Soil..... .' ---�=.. aQ0�`-� .!..�-' ._.":_ ..._ `' � t "> .�---'•&M _ -
- ----- -
x - ----.
V - .•- --........••• --............... ...
W
-------------- ---------------------------------------------------------------------------------------------------------------------------•-------•-----------------------••---•--•--•:......--.••----
Z.
Nature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has,been sued by the b rd of health.
J� v..
Signed -- - -------------- -------
Dare
Application Approved B ::-........ ':r• ' '`��.' ----------�� ^------------------------------------------- � f r ---!'--=_
- Dace
Application Disapproved for the following reasons: �...................... ..... .............. ............................. ........
------------------------------------------------------------------------- -- .........----------............................................................------.-- --------.......------........... ----------------------------------------
Permit No. J �...................... Issued --------....... ---'f... ./.....-=
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rt _
�t ' .�1......--... OF � 1 ,... �
Trrttftrate of Tonipliartre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �) or Repaired ( )
by.........^----------------------------------------------------------------------------- -- -------------------------------------- ------------------------------------------------------------------------------------------------------
has been installed in accordance withl the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...�fei
. .... - -.g..... dated ......7�.:-.1.-.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .:........ ...�....-...-........ ............................ Inspector .........•----- ... ...----------------------.--------..--------------
1 =
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{i ...................... ...... ....
No.. ...... '...._...:.'.. FEE....`.: '::...
Dinvnnal luorkii Tnnitrnrtiun amit
Permission is hereby granted......................................................-••--•--••--••--•-----•••-••--•••-•----•-••-•-•-•-•----•-•••--••-•-••-.._..............
to Construct ( )_or, Repair ( )-an Individual Sewage Disposal System r
at No... , ,�y................. f � '.C�l:''"� ..: .t....................................................................................
`
w Street � r.
as shown on the application for Disposal Works Construction P it Nod_"__ "j : Dated......... -----........
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✓ //y DATE........T-----------------------•---��---............................... Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: `�
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