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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI D rD'�B.S R19IS
Governor 0 miS5I ner °
*t�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART A
CERTIFICATION �9 >
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM kk S U k � o� Q
Name of Owner KOLARICH -9 i
Address of Owner: SAME �� ,Ql
Date of Inspection: 6/17/99
Name of Inspector:(Please Print)JOHN GRACI <�
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a
Mailing Address: nla
Telephone Number: n/a
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Evalu 'o y the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:6/18/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. f 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 SYSTEM PASSES TITLE V INSPECTION.RECOM MEND PUMPING SYSTEM EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.
III revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
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.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nLa 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.
nta 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.
Wa 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
obstruction is removed
distribution box is levelled or replaced
nia 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
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
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 the public health,safety
and 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 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 nLa- (approximation not valid).
3) OTHER
n&
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:5/17/99
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 nta.
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,
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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
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 400 feet of a 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 nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 8 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:5/17/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
4
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 built 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.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
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)1
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17199
FLOW CONDITIONS
RFSIDENTIAI
Design flow:AQ g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):4
Total DESIGN flow: MR
Number of current residents:2
Garbage grinder(yes or no):]CES.
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):JLQ
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): nta
Sump Pump(yes or no): NO
Last date of occupancy: Wa
COMMERCIAL/INDUSTRIAL
Type of establishment: nIa
Design flow: n(a gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):�LQ
Industrial Waste Holding Tank present:(yes or no): HQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):No
Water meter readings.if available:n&
Last date of occupancy: n&
OTHER: (Describe)
nfa
Last date of occupancy: nla
GENERAL INFORMATION
PUMPING RECORDS and source of information:
7 YEARS AGO
System pumped as part of inspection:(yes or no):YE;i
If yes,volume pumped 111111 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&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
. 35 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no) XG
revised 9/2/98 Pang F nr 1 I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
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:
nta
Type:
leaching pits,number: nLa
leaching chambers,number: -n&
leaching galleries,number: j3La
leaching trenches,number,length: Wa
leaching fields,number,dimensions: WA
overflow cesspool,number: 6'X6'BLOCK CESSPOOL
Alternative system: n&
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE PIT HAD 2'OF WATER IN IT
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: Wa
Depth of solids layer: WA
Depth of scum layer. Wa
Dimensions of cesspool: nLa
Materials of construction: n&
Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)nfa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:Wa
Depth of solids: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
• b
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
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)
n/a
O
O
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6117199
NRCS Report name: Wa
Soil Type: Wa
Typical depth to groundwater: nta
USGS Date website visited: n&
Observation Wells checked: MQ
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
X 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
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
-�• � cap � , �
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION v
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM 4
Name of Owner KOLARICH fl o �60
Address of Owner: SAME
Date of Inspection: 6/17/99 Q MAY z Z. 1999
Name of Inspector:(Please Print)JOHN GRACI
l am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: n/a ``k
Mailing Address: n/a
Telephone Number: ' n/a i
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Evalu o y the Local Approving Authority performing at the time of the inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:6/18/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. f 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 SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:5117199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ 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.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n1a 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.
nLa 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.
nta 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
obstruction is removed
_ distribution box is levelled or replaced
Wa 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
revised 9/2/98 Page 2 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
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 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 nLa_(approximation not valid).
3) OTHER
nLa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6117199
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 n1a.
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,
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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
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 400 feet of a 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 nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address, 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:5/17/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
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 built 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.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
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
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:J44 g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):4
Total DESIGN flow: 4411
Number of current residents:2
Garbage grinder(yes or no):YES
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): DA
Sump Pump(yes or no): NO
Last date of occupancy: nLa
COMMERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: nLa
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): r1Q
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:nLa
Last date of occupancy: nLa
OTHER: (Describe)
nLa
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
7 YEARS AGO
System pumped as part of inspection:(yes or no):YES
If yes,volume pumped 10111L 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&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
35 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: Z
Material of construction:_ cast iron 40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: Z'
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): 11LQ
nLa .
Dimensions: 6'X6'BLOCK CESSPOOL
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3r
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: 17""
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete metal_ Fiberglass Polyethylene_other(explain)
nLa
Dimensions: Wa
Scum thickness: Wa
Distance from top of scum to top of outlet tee or baffle:i3La
Distance from bottom of scum to bottom of outlet tee or baffle Wa
Date of last pumping: n1a
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.)
Wa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nLa
Capacity: Wa gallons
Design flow: Wa gallons/day
Alarm present: NO
Alarm level:jilA- Alarm in working order:Yes_No_ NO
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nta
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:nLa
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
13La
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6/17/99
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:
nLa
Type:
leaching pits,number: nLa
leaching chambers,number: jiLa
leaching galleries,number: j3La
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nLa
overflow cesspool,number: 6'X6'BLOCK CESSPOOL
Alternative system: n&
Name of Technology: j3La
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAD 2'OF WATER IN IT.
CESSPOOLS: _
(locate on site plan)
Number and configuration: nLa
Depth-top of liquid to inlet invert: n&
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: nLa
Materials of construction: Wa
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:nLa
Depth of solids; n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nta
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:5/17/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 1 00'(Locate where public water supply comes into house)
n/a
O
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 THYME LANE OSTERVILLE BACK SYSTEM
Owner: KOLARICH
Date of Inspection:6117/99
NRCS Report name: nLa
Soil Type: nLa
Typical depth to groundwater: nta
USGS Date website visited: nLa
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
X 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
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
TOWN OF BAPUiS A$LE
w4 LOCATION ��� SEWAGE #
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VILLAGE � ASSESSOR S.MAP & OT
INSTALLER'S NAME&PHONE NO.
1
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Ow t (size)
NO.OF BEDROOMS
BUILDER OR OWNER II p
PERMITDATE: COMPLIANCE DATE:
i
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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TOWN OF BARNSTABLEL
LQCATION .� � SEWAGE # .r
VILLAGE ASSESSOR'S MAP & LOT iGs 0104
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (J' (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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
I -
Alto _
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