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HomeMy WebLinkAbout0122 TANGLEWOOD DRIVE - Health 122 TanglewobdDrive ' " yp Qsterville A� 121 061 F, m 1 ' o llll UPC 1204 N :2- 53 N r�o ° 14 2-0 J i�J� � r U w i�� Wcti J s r,r , 4/T!'T/" �]��ry�f' A _ � e- ���, �:5• '+�` `,.,y`J s � Y i' '; .. f. , '' ., � `�� .� (,IJ•�'' (c,•,Yf, , 1�'ems, � �" g `'� _ �t, l/ t r a - r _ A s a s e r r „n a ,� - ,. .. � �- ! ^� - � • �.eb. yr a. J i r n y ' .v`_ k .•t`^ a r - fit' > i -�+ r - '4 iR� ''t 4�. 3• `a3 yN 5 ,qn: �7 -. s v 4° - t w " .,. .. t � . .z`� s rLs� 'Yi. ��, •a f ..� ti:_• V� ... � i r _. #". ' t .. � 4 , .9 R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments copy 122 Tanglewood Drive — Property Address Lisa Branzetti Owner Owner's Name/ raj' information is required for every Osterville ✓ MA 02655 October 1, 2020 page. City/Town State Zip Code Date of Inspection [ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information c5'! (Lf�a-3 filling out forms on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 and the inspection was performed based on my training and experience in the proper function inspection; a p determined After conducting this inspection I have . maintenance of on-site sewage disposal systems. 9 P and a 9 P that the system: ` 1. Passes 2. Conditionally Passes 3. Needs'Further Evaluation by the Local Approving Authority. 4. Fails a October 5, 2020 Inspector's Ignature 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 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. 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.7/26t2018 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 . 122 Tanglewood Drive Property Address --- Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1 2020 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: 2) 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*.dr the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfi ration or tank failure is imminent. System will pass inspection if the existing tank is replaced witt a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection . it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is I s than 20 years old is available. ❑ Y ❑ N r ❑ NDAxplain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1, 2020 page. City/Town State Zip Code - t Date of Inspection C. Inspection Summary (cont.) 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 5 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 replaced ❑ Y El N El 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): 3) Further Evaluation is ReYreire the Board of Health: ❑ Conditions exist whichurther evaluation by the Board of Health,in order•to determine if the system is failing toublic 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 122 Tanglewood Drive V Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coat.) j ❑ 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 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: 1 ❑ The system has a septic tank and soil ab orption system (SAS) and the SAS is within 100 feet of a surface water supply or tributa to a surface water supply. ❑ The system has a septic tank and SAS nd the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and AS and the'SAS is less than 100 feet but 50 feet or more from a private water supply well Method used to determine distance: �z This system passes if the well wat r analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent a d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th no other failure criteria,are triggered. A copy of the analysis must be attached to this form. c. Other. .F 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool a ® 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetts Owner Owner's Name information is required for every Osterville MA �02655 October 1, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- El10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 00 feet of a surface drinking water supply ❑ ❑ the system is win 200 feet of a tributary to a surface drinking water supply the system is/l'ocated in a nitrogen sensitive area (Interim Wellhead Protection El El Area—IWRX) 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name w information is required for every Osterville MA 02655 October 1 2020 page. Cityrrown 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 C.4 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 ® ❑ 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? ® El available 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. ® El approximation 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 16 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < � 122 Tanglewood Drive V� Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549 GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? - ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2018= 98 GPD 9 ( Y 9 (gP )) 2019= 102 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.7I2k018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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., a Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank prese ? ❑ Yes ❑ No Non-sanitary waste discharged to a Title 5 system? ❑ Yes ❑ No Water meter readings, if availab Last date of,occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owners records: Pumped'3 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: rt — + t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c� Commonwealth of Massachusetts ' Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is Osterville MA 02655 October 9 2020 required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System installed 2/18/1982. D-box replaced 11/22/2016.,Certificate of Compliance on file at Health Dept. Were sewage odors detected'when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2.8 Depth below grade: feet Material of construction: ❑ cast iron' ®40 PVC ❑ other(explain): •{ Distance from private water supply or suction line: + n/a . . • feet Comments (on condition of joints;venting, evidence of leakage, etc.): y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA _ 02655 October 1, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. 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: I 8.5' x 4.5' x 5' 1000 gallons Sludge depth: 21, Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness Distance from top of scum to top of outlet tee or baffle 14„ Distance from bottom of scum to bottom of outlet tee or'baffle How were dimensions'determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels`as related to outlet invert, evidence of leakage, etc.): Inlet tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Recommend maintenance pumping every two years with full time use. t5,insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 r October 1, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fi erglass ❑ polyethylene ❑ other(explain): Dimensions: -- Scum thickness Distance from top of scum to/o'futlete or baffle Distance from bottom of scumoutlet 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: - -- - gallons per day t5insp.doc•rev.7/26/2018 -ritle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1, 2020 e. City/Town State Zip Code Date of Inspection page. P 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 a/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): - 0" 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.): One inlet, one outlet. No solids carryover. No high waer staining over outlet invert. H-20 DB-3. 2' below grade. Riser brings cover within 6" of grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name ` information is required for every Osterville MA 02655 October 1, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): e Pumps in working order. ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments(note con dition.of pump ch ber, condition of pumps and appurtenances, etc.): f * If pumps or alarms are not in working order, system is a coriditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: —--- Type; ®. leaching-pits number: 1 6'x 6'w/stone ❑ 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 c Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary AssessmentsM 122 Tanglewood Drive L- Property Address - Lisa Branzetti Owner Owner's Name information is required for every Osterville MA, 02655 October 1 2020 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.): Liquid level 4' below invert at time of inspection. High water staining 6" above current level. Clean stone visible in side wall with mirror. Riser brings cover within 10" of grade. . r 12. 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 inflo ❑ Yes ❑ No- Comments(note condition o 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 ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is Osterville MA 02655 October 1 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: - Dimensions Depth of solids Comments (note condition of soil, signs of draulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive _ Property Address Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1, 2020 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: ® hand-sketch in the area below El drawing attached,separately 4 ` a - . . rl�3 r . 0. D 71 'i t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Lisa Branzetti Owner Owner's Name information is Osterville MA- 02655 October 1 2020 required for every , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5feet 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: 08/04/1981 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-.(attach documentation) ® Accessed USGS database -explain: maps.massg is.state.ma.us/oliver.ph p You must describe how you established the high ground water elevation: Test hole in 1981 to,180" (elv= 78)found no ground water. Base of leach pit at elv= 85. Slope to rear of property drops below base of pit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Tanglewood Drive Property Address , Lisa Branzetti Owner Owner's Name information is required for every Osterville MA 02655 October 1, 2020 page. Cityrrown 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 i t5imp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 fad - a�/ Commonwealth of Massachusetts z - Title 5 Official Inspection Forms Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 122 Tan lewood Drive Property Address Kathleen Dalton txt Owner Owner's Name 1+ information is t77 required for every Osterville MA _ 02655 November 23,2016 � page. City/Town State Zip Code Date of Inspection W W Inspection results must be submitted on this form. Inspection forms may not be altered in fiAy 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-do not Patrick T. Sullivan use the return — -- key. Name of Inspector _Ready Rooter Excavating _ r� Company Name P.O. Box 89 F` Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 _ S112843 . 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 �-� November 28, 2016 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 systerri'owrier 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Kathleen Dalton Owner Owner's Name information is required for every Cisterville MA 02655 November 23, 20,16 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: ® I have not found any information which indicates that any of the fail Lire'criteria described in 310 CMR 15.303 or in 310 CMR.15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: t B) System Conditionally Passes: [l 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, ND)for the following statements. if"not determined," please explain. / r 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. r *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): f: r f 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 17 - Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f _ 122TanglewoodDrive Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville MA 02655 November 23,_2016 _ 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 d`ut or high static Water.Ieve! in the distribution box due to broken or obstructed pipe(s) or due tda 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 (Ex plain_below): ❑ obstruction is remove ❑ Y [] 'N ❑ ND (Explain below): ❑ distribution box is Iweled or replaced ❑ Y ❑ N ❑ ND (Explain below): f ❑ 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): : j 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 Boa, of Health determines in accordance with 310 CMR` 15.303(1)(b)that the system is,�ot 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 ( 122 Tanglewood Drive Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville MA 02655 November 23, 2016 —_ — page. CdyrTown State Zip Code Date of Inspection B. Certification (cont.) . t 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 tributaYr�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 aseptic 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' J !r ** This system passes if the well waternalysis, 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,Ao other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i 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 t6overloaded or . clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 '/2 day flow _ Sewage Disposal System Page 4 of 17 t5ins•3113 Title 5 Official Inspection Farm:Subsurface Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 122 Tanglewood Drive Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville MA _02655 November 23, 2016 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. El ® 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 1.00 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"ys" or"no" to each of the-following, in addition to the questions in Section D. / Yes No the system/iiis * in 400 feet of a surface drinking water su I ❑ ❑ y9 pP y ❑ ❑ the systemin 200 feet of a tributary to a surface drinking water supplythe systemted in a nitrogen sensitive area (Interim Wellhead Protection Area—IW 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 i 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. l5ins•3113 - - Title 5 official Inspection Form`.Subsurface Sewage Disposal System•.Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 122 Tanglewood Drive Property Address -- Kathleen Dalton__ Owner Owner's Name information is Cisterville MA 02655 November 23., 2016 required for every --------- ---=------- -. - 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? ® ElWas 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 C1s at issue approximation of distance is unacceptable) [310 CM.R 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) 549 GPI) t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6'of 17 iL i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. - 9 P Y rY 122 Tanglewood Drive Property Address -- Kathleen Dalton Owner Owner's Name information is required for every Osterville MA 02655 November 23, 2016. —__— page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑. Yes ® No Water meter readings, if available last 2 ears usage d 2015-`150 P D g ( y g (gP ))� 2015= Z6 GFD Detail: Sump pump? ❑ Yes M 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: 15ins•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 122 Tanglewood Drive Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville MA 02655 November 23,2016 page. CityrFown State Zip Code Date of Inspection. D. System Information (cont.) Last date of occupancy/use: September 2016 Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter pumped 11/2010 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 { r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville _MA 02655. November 23, 2016 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 02/08/1982 _ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2,8„ feet Material of construction: ❑ cast iron ® 40 PVC El other(explain): Distance from private water supply well or suction line. n/a 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: 8.5.x 4.51 x 5' 1000 Gallons Sludge depth:de the 2 15ins•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 '� ,•'' 122 Tan lewood Drive Property Address Kathleen Dalton Owner Owner's Name information is Osterville MA 02655 November 23, 2016 required for every _ _ 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 33" Scum thickness Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to.bottom of outlet tee or baffle 14' How were dimensions determined? Tape measure and dip tube.— Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,. liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Tank does not need pumping at this time. Recommend pumping every 2-3 years, with full time use. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: r' ❑ concrete ❑ metal %❑ fiberglass ❑'polyethylerie ❑ other(explain): Dimensions; J Scum thickness / r Distance from top of scum to/top of outlet tee or baffle Distance from bottom of s um to bottom of outlet tee or baffle Date of last pumping: Date i t51ns•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 122 Tangle_wood Drive Property Address Kathleen Dalton Owner Owner's Name information is Osteryille MA_ 02655 November 23, 2016 required for every _ _ _ page. City/Town State Zip Code . Date of Inspection D. System Information (cont) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other,(explain): . Dimensions: -- f` Capacity: % — 1` gallons Design Flow: gallons per day Alarm present: / ❑ Yes ❑ No. Alarm level: ,'� — Alarm in working order. ❑ Yes ❑' No f 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 122 Tanglewood Drive _ Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville MA 02655 November 23, 2016 - _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cent.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): D-Dox installed and inspected-just.prior to Title 5 Inspection. H-20 DB-3 with riser 6"below grade 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: 15ins•3/13 Title 5 Official Inspection Form:.Suosurface Sewage Disposal,System:Page 12 of 17 . I Commonwealth of Massachusetts _ Title 5 Official Inspection Form -J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 122 Tan lewood Drive Property Address Kathleen Dalton Owner Owner's Name information is required for every Osterville _ MA 02655 November 23, 2016 page. CitylTown _ State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 6'x6'w/2' of stone. ❑ 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.): Leach pit dry at time of inspection. High water staining 2.5' below invert.5 rows of holes with clean stone visible through side wall. Riser brings'cover within 6" of grade. 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 groundwatef inflow ❑, Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts - Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Tanglewood Drive LISP _ Property Address Kathleen Dalton Owner O -- __ wner's Name information is required for every Osterville MA 02655 November 23, 2016 _ page. CityRown. State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: - - Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 122 Tanglewood Drive Property Address Kathleen Dalton Owner Owners Name^ --- -- -- information is required for every Osterville _MA 02655 November 23, 2016 page. CityfFown — _— 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 57 7 in�is f t5ins•3/13 Tme 5 Ofiidal Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 ' Commonwealth of Massachusetts l — . Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for - _ Y Voluntary, ry Assessments �M 122 Tanglewood Drive Property Address — Kathleen Dalton Owner -- - - -- - _ Owner's Name information is OSterVllle required for every _ MA_ 02655 November 23, 2016 page. Cftyfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells >7, Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: Z. Obtained from system design plans on record If checked, date of design plan reviewed. Datatee 1981 D . ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: maps.massgis.:itate.ma.us/oiiver�h p You must describe how you established the high ground water elevation: Test hole in 1981 found no ground water at 180", elv= 78. Base of leach pit at elv= 85 per engineered Mans. Base of leach pit 1_0' below grade.Slope in rear of property drops below base of leach pit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:SU6SUff3Ce Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposall System Form - Not for Voluntary Assessments 122 Tan wood, Drive Property Address Kathleen Dalton Owner -- - ---. Owner's Name ----- - information is required for every Osterville _ A 02655 November 23, 2016 page. Cityrfown 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 InspectionForm:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION i� � ,�\� µSEWAGE#Qt!D(C,- - VILLAGE ASSESSOR'S MAP&PARCEL l �� INSTALLER'S NAME&PHONE NOS { �,► -, ,re_ a SEPTIC TANK CAPACITY 1 l S-627 Wlf 660- �-c,&6L� )'� (size 'x LEACHING FACILITY:(type) v 6 'C../ 3 NO.OF BEDROOMS OWNER -`�lr���b •�, PERMIT DATE: ` `6 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';;��, vl C� 3 l e� 1 No. 45 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppiitatiou for JMisposal *pstrm Coustruttion permit Application for a Permit to Construct( ) Repair(�-4pgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. QQ�.p r N j -r Owner's Name,Address,and Tel.No. ::k Ol:�O J S �.c.5 ti C',oJ�pw Assessor'sMap/Parcel to ` �G ` 0 '� ,� " 0 l C7\� '$a S--Z Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1;?0 Type of Building: Dwelling No.of Bedrooms �SLot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank (00�D p�l�' Type of S.A.S. (,—,,AcJh, Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued ---------------------------- ------------------- ------------- i� ! . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer: ' Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for VspoSal 6pstem Construction permit Application for a Permit to Construct( ) Repair(VI"Upgrade( ) Abandon( ) ❑Complete System ErIndividual Components Location Address or Lot No. �a�`�^( ��rlv' Pr% Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a Installer's Name,Address,and Tel.No. S-C)`2-777-6 �5 Designer's Name,Address,and Tel.No. l � , .r�j Gd-,a �� /,a, Za x '; � to vz=:;7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date q Y1 Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) J Q J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed G —� Date Application Approved by Date Application Disapproved by Date for the following reasons s Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(./� Upgraded( ) Abandoned( )byrx--wi ��s" r��c. :y,G, at `tea —�.r•���� ]c� }�, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No9c/tf dated Installer t`��pG � �Jccc��i Designer ) , #bedrooms Approved design flow A) gpd The issuance of this pe t shall not be construed as a guarantee that the system will nc on as designed. Date ( � �(� Inspector ' i(l No. / `` r - — - FeeTHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -Disposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair(V'J' Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Consstruc J ion must 'e completed within three years of the date of thi permit. Date !/��a' � Approved AsBuilt Page 1 of 1 0/1%0 . LOCATIOp SEWAGE PERMIT NO. cr) i VILLAGE foa/ -66l - O I.NSTALLER'S NAME iADDRES.S I U I L D E R OR OWNER DATE PERMIT ISSUED �� _g/ DATE COMPLIANCE ISSUED 1� =14— A FRONT i000 TANK ON I7tr e http://issgl2/intranet/propdata/prebuilt.aspx?mappar=121061&seq=1 11/23/2016 L0CATIOkt, SELVAGE PERglT p0. VtVV DR, VILLAGE INSTA LLER'S NAME 8 ADDRESS B U I L D E R OR OO113 ER DMA Wf;: A 1366 DATE PERMIT ISSUED DATE C0MPLIAWCE ISSUED jd2 7- - 1 t PRaNT u t000 rm K e �m s 1066 pig a _ P.. N� rft--- F.H$.?�?.._-'...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................ ......................OF...........I.............................:­ .......................................... Appliration for Bh4pos al 10orkii Tnntrnrtinn Vamit Application is hereby made for a Permit. to Construct ( /or Repair ( ) an Individual Sewage Disposal System at: ......Z G_. ----.22 !fir---- - - -------------------------------------------------- Location,.�d .............................................Lot.No. Owner Address :. eal .ill P&..... ........... ---••................. ....... ... Installer Address Type of Building Size Lot----- feet Dwelling—No. of Bedrooms_.......................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons__......_ _. Showers — Cafeteria P a YP g ---•-------- P -•---------- ( � ( ) Otherfixtures --__-•-------------------•------------------------------------------------------------------------------------ W Design Flow..................�.L!�............gallons per person er dad. Total dailp flow.......]�15..._J_._...............gallons. WSeptic Tank—Liquid capacity.././�..gallons Length-__ `,_.. Width-_J'1A.- Diameter.�_,�7. Depth...._..17! . 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 ( lJj , Dosing tank�( ),_ '-' Percolation Test Results Performed ----------1�-.R'0��r--.._�,fil f .................. Date......... _.....__.. Test Pit No. 1................minutes per inch Depth of Test Pit----- Depth to ground wa er..._..._ d ! Test Pit No. 2................minutes per inch Depth of Test Pit......,12.,,..... Depth to ground water........A/PlA.4- ODescription of Soil----------------- ...... ------------------•------------------------------------------------------------------------------•---------------- V -•---•-•---•-------•--••••--•------•---------------------••---•-----------------•••------•-•----------------•--------------•---•-•-•---•------•----------------------•••••---•---•----•-------•-------- 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,L?1':.p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been s ued by the bogrA of liea th. - ------- -- ----- •••. - e/ ApplicationApproved BY-- -- ----�---�----�----• ----•---•------------------•------•------........--•---•------ ----•---G3--•-�f--•----•----.. Date Application Disappro t following reasons--------------------------------------------•---------------------------------------------------------........... .................................................--..................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date �3 /.. Fps............... N�,�..yy..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..........................._...........------------------------------..................... Appliratiou for Ui5pnsal Works Tnnitrnrttun amit Application is hereby made for a Permit to Construct ( V050"or Repair ( ) an Individual Sewage Disposal System at: _ - _ Location•Address '1 _ or Lot No. ....._.....C...:.:....-•----•....... ..... `'-•-•-••-....J=-.............. --•-•-------------------------------•--•-• ••----...................----..............--- _ Owner Address Installer Address 7 Q Tvpe of Building Size Lot..... .....:...............Sq. feet aDwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( } QI Other—Type of Building ............................ No. of persons..........:................ Showers ( ) — Cafeteria ( ) a Other fixtures. ................................. ._._ ....._gallons per person er day. Total daily flow____-__-:._ :...............................gallons. W Design Flow--------•-----------�----.---} •- g P P P Y• WSeptic Tank—Liquid capacity___/../_,/__gallons Length____ ...f_ _.. Width__.?__.`._'_.. Diameter.-=f__:_..... 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 1-1 .. .� '............ /. ./. Date . Percolation Test Results Performed by....__._...:.:............ Date.._________:._.......................... aTest Pit No. I................minutes per inch Depth of Test Pit.......j'_:'........ Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit........'__%....... Depth to ground water...................... . .........................................................................................................................•-------....--•--...........-_••--. ` ......................................................... Description of Soil---------------------- ---------------------------------------•-------------------•-----•------•--•--------------- x V ........................................................-...............................................................I...............................................------------------------------ W •--•-•-•-----------------• ------------=----------•••-•--•---------•-------_-..--_-------•--.._..............r-......----_....__......•••-----•••--••---•-•-•-••----•----••-•--------•--•••-_..... VNature 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 L?T; y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. ; xled....... . .. ../ ;r /1te Application Approved BY,, % :/ r' =--W....••----. Date Application Disappro o�e following reasons-------------------------------------•-------------------------------------------------------------••------•---•- ---------------•-._....-•-------------•-----•--------•--•----.._..--•----••---••.._....---•-••--•-------•-••-•----------•---•-•-•--------•-•----•-•------••---•--------••------•---•----•---•----••----- Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR%DF" HEA T Trrtifirate of Tompliana TI IS TO RTIFY -the Individual Sewage Disposal System constructed ( or Repaired ( ) by /..._7r_ c .'/ •�. .Installer - ---•--••l-----•---------- ----•---•-•----•-•-------•------------•------------------------------------- has been installed n ac rdance with the provisions of TITLE � of.-The State Sanitary�o e a de cribed in the application for Disposal Works Construction Permit No. x_.Gr__.�.................... dated_?.__/.�__..� ______-__-_-_-_-_...•_- THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................2= Y.:.Z ....................................... Inspector.......... - ........................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF AL� NoFEE................d'.................... ...----- i rrr nrk ion amit Permission�l"iereby granted.. ____ �''`I .. -•••-•- to Construct (F) or Repair �) an Individual age/' sposal System atNo. --- --•••--- --•-••------------ Street as shown on the application for Disposal Works Construction Permit No....................... .•• Board of Health� Dated..........................................: :--------------- DATE------------------------��_--/...`/��/ FORM 1255 HOSES & WARREN, INC., PUBLISHERS J Q N � 4 y o+-$ • 2� ev �3 Iwo• (OW `00 ,? Q►� op 2 . p 000 �.�'-04 ,. , • SMITH, JR. v, j' (Uc;E. 2 A�F fitONAL ���� SCA LA, 4, 196 U C-� W 5 �5.0 91 � � 1. 0 ��' D►sT 84c ti I / q r a • _3._ mcmZ" t/s•— �Luw0.s/�cj s�nt ' �OOQC�. Cd►G• �I r L1 p dd Go►dC LEALNtIJG� PrT ` `jGP�tc. r4N �L ! VZ,O A A L � a A AA A !Jrwa Sr,,m Bo-r. P+T ELAY 1 o Pao �lO N ZA4 A)1I DW-o P TEST 1--�f::"oRM Ev j V l_ j Z'7, f Z.6E.OR00MS x I l0 GPD PD LE.AcW$46, ie7ct tQo CpAREvaUE Dispo5AL U$E ! O©OGAL.SEP ICTAN C•APAcITy PP-ov1DeD �cT-roul Tr`5 zx 1 , O SA�� 't ©67 sit a x G K 7, 5 i o-ra I- CA FA C IT-i !70 v! P43D 54 9 .7 G VP rc bTu i T� IV ©TE D tSPOSA� �YST�M Dc s lc�►�E D /� aC_oGZvAt-4C4F- w , T'f-4 PP-ovrsJ0NS C).F T'f T L E 7,9• D ($O �l0 61rovK WC_4f Cmcoua4rcd OILTRAY'A S�IGIET AsBuilt Page 1 of 1 L0CAT,10# SEWAGE PERMIT VILLAGE to/,- d61 — N ' INSTALLER'S' NAME i ADDRESS I U I L D E R OR OWNER DATE PERMIT ISSUED ~ejL } DATE COMPLIANCE ISSUED z FRONT r - icxx:� r�wK i Sf.rwx http://issgl2/intranet/propdata/prebuilt.aspx?mappar=121061&seq=1 10/8/2013 Page 1 of 1 l /Cl Stant David From: Amanda Kundel [amanda@oysterre.com] Sent: Tuesday, October 04, 2016 2:35 PM To: Stanton, David Subject: 122 Tanglewood Osterville Hi David, I'm hoping you can offer some insight on this property. There isn't a file or, any recent inspections according to the woman I met with at your office today. I am listing this property and trying to determine how many # of bedrooms the septic is designed for (or allowed by location). Thank you, Amanda Swift Kundel Sales & Rental Specialist Oyster Real Estate 829 Main Street Osterville, MA 02655 Mobile: (508) 360-7364 Office: (508) 420.1000 Fax: (508) 428-1623 Amanda Oysterre.com www.oysterrealestate.com Licensed in Massachusetts Broker#009521133 10/5/2016