HomeMy WebLinkAbout0134 TOWER HILL ROAD - Health 134 TOWER HILL ROAD
OSTERVILLE
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Commonwealth of Massachusetts
• Title 5 Official' Iftpecti®n 'Form,
!d MI Subsurface Sewage Disposal System Form =Not.for_Voluntary:Assessments ."
134 Tower Hill Rd
Property Address " • . +.
Mary Swift
Owner Owner's Name - Yr
information is r,
required for every Osterville;i• Caycll0 '-,4" MA 02655 5-12-21- 7`
page. City/Town • .if �; {S 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.
, , .- kp, r.` 1,., . _ ,r •I I ','ix":.7- c
A. Inspector Information
Shawn Mcelroy R---
,:1 s.- - - , r - - r L.etn.j"•� - r . : r!.+
Name,of Inspectorl
r .. . +++ . .. ' T..t 1 t :�.?r;..G 1 Il � r t t. ��r•. ..� .� `' .f 4
Upper Cape Septic Services
Company-Name
P.O. Box 73 -
Company Address
East Falmouth 1 416 r ll-M I ,�n rliN kv! MAi71 02536
City/Town State Zip Code
(508) 495-0905 S13971
Telephone Number License Number
B. Certification_
I certify that:l am a DEP approved system inspector in full compliance with;Section 16.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage d sposal system'at thepropeity address listed
7 J above;the information reported below,is true, accurate and complete as of the time,of my inspection; and
the in-spectlor was'pertormed based•on my training and experience !n'the proper function and
' '-N" ''maintenance of ori`site sewage disposal systems.After conducting this'inspection I have determined that
the system: ; ,:,•.. ,, �..� r ►:.r.. ,
1.t� ® i Passes"{ �r.: :�•� I ,l '01 t�i i3 =ram.r•, `rl oil wy` it?! :-f.c-
r f1)r r.!n 3 :., •'-rEi) .f:�r,'�fYi^_•a .
�, • :r '�a: f , : 2. ;❑ •Conditionally Passes,
y 7 ..a 'i'1 of i r��� .. trr . ,�1a,`. ,n f S. l ,e.
r .. •i,.? Y, fi .ru r�; .._ '1��:tff$i r ,[ E r . ' � "r+ 33}Prt�. n. � f'd�#;X
:❑r Needs.Further,Evaluation;by,the;Local Approving Authority::, *rl;
4. ❑ Fails
ry r }•!€:a (I%l,;1+ri-,: e c' Ht "4r•'r! ..pT� ,!,,;ts,^�;Jta"I:.. l' r)r"` � '
J ri.• 1' r' u i w .t ? 1, a'. I. '�:. ,
'.1l 5'1j: 1f i•� f.is ' 'n tom: 7f-t"ar uT; :n[I} f'r1;1'':at, 1i _,--a 1�'t13Cn
-„� 1-5-12-21 ,.,M
Inspector's Signature y"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
Y p 9 P Y 9
10i000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the.DER 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.7/28/2018 v r, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
4. ,': Title 5 Official: In- Fd'rm' '
I� wa
r.II Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments -
r�
134 Tower Hill Rd
Property Address "
Mary Swift
Owner Owner's Name ,.
information is '
required for every Osterville . MA 02655 5-12-21
page. City/Town t State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or5 and all of 4'and 6.'
1) System Passes:
® 1 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:
r System is in good working order with no sign of failure. -
a
2)`f System Conditionally"Passses:
a'I
❑ 'One or more system components as described in the "Conditional Pass"section need to be
f replaced'or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass. I
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exhitration or tank failure is imminent. System will pass
inspection if the existing tank1s replaced with a"complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N r ❑ ND (Explain below):
v A
r • . -i � i it + \i1 `1' { 4 1 F 1.
+ i _ .. ♦ .. tea. -. ... i. , .. .... ... ..
. r der . • .. ,+1 +. �^t,j S'. _•♦t�+� r. alr
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts I
Title 5 Official' nspection, Form)
�A Subsurface Sewage Disposal System Form -Not forVoluntar y.Assessments,-,-,
134 Tower Hill Rd J,H
Property Address 70
Mary Swift
Owner Owner's Name
information is
required for every, Osterville MA 02655 5-12-21� Yrti
page. City/Town I 41:, State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally passes,(cont.):
El Pump Chamber pumps/,alarms not
4�; System will pass:with B I oard of Health approval if
ired.- Y1 -I -� f", ".]e —
_j 0j -'. ..:,3
:V'. pr, r''; .-ritrflok icvkl* -f Pit"'*"141 1 T a T!,a, r OIL,
El Observation of sewage backup or break out or high static,water.levelin the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
approval-� 8 ' '(d_6UH6alth):
pass inspection] (with' of oa
,
".4 !it 14 1 E 4,L A -I�J:
El brokek'pipii(s) are replaced' `ND-(Explain below):
, I [D 1. I . - . r
-obstruction is remove FvY
*it 'ND (Explain below):
wr
rX 11 .1 "distribution'-Nix is leveled orreplaced Ely' El N -EYND (Explain below):
in! 'Y10"o-C '-I h k ;3 414t"h 4 CLIi, b-l"V "M et•e2.%ij ;-sup�e e."'.I
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fTj1,,4 (it U%,!:.toz 4,0
R 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):
El broken pipe(s) are replaced DY ON 0 ND (Explain below):
D obstruction is removed Ely EIN R ND (Explain below):
3) Further Evaluation is Required by the Board:of,Health:
0 Conditions exist which require further evaluation by,the Board of Health in order to determine if
i *fail"rid to 11.1 .14, public " ' i 'k_j "_ W-i'""' '-�" '-�"r
&�s`ysf m s iprotect pu ic health, safety o environm6ni. -- -
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functi
oning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7126/2018 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
s r Commonwealth of Massachusetts
Title 5 official lfispectionaFor i
i Ol Subsurface Sewage Disposal System•Form -Not for.Voluntary Assessments
134 Tower Hill Rd '��•.I s
Property Address
Mary Swift Y
Owner Owner's Name
information is
required for every Osterville 'f - MA 02655 5-12-21
page. City/Town o , `. State Zip Code Date of Inspection
C. Inspection Summary (cont.) .�, �. � •t "
❑ Cesspool or privy is within 50 feet of a surface watero
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The-system has a septic tank and soil.absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. --
,r ❑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:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
1 c. Other:
.s 1• i t• ti'-
r
4) System Failure Criteria Applicable to All Systems: I
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 •' " V_
® 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.7M/2018 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System•Page 4 of 18
f
r Commonwealth of Massachusetts c
w,
hi Subsurface Sewage Disposal System Form =Not for•Voluntary Assessmentsh ri . si=j
a'
134 Tower Hill Rd r,�' ►� �., ,;
Property Address w
Mary Swift
Owner Owner's Name
information is Cisteryille
required for every ,? r -;tri MA 02655 5-12-21-i
page. City/Town' r ^s si. State Zip Code Date of Inspection ,.
C. Inspection Summary (cont.) 4 tfIca,
System"Failure Criteria Applicable;to;All Systems:
1 ,tr, ,.`•r ,a.13 •a.. :I , I.Jt"i ; rf;,y,..� �rftf G1 c ,, ' 'r '!1- { +,
131r.,': +? 1 YeS1.17 •,Noa
p -,�. iy ' i_ •.,..^ ,k ..0 i t r: ., fit;"I ,J 1 ,` -a
..n r ,. �J I.i,1
Static liquid level in"the distribution boz above out invert due to an overloaded
f or clogged SAS or"cesspool'
Liquid depth in cesspool is less than 6" below,invert or available volume is less
*.El-,iE%i, t.than '%zdayflowi
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
+.� ' ' ,_ b;si� �, ❑u. ,. ®,:�, Any portion,of=the.SAS;cesspool or;privy is below high'g"round water elevation.
# ;,❑ri ,;; ❑ ; ,r. Any portion of cesspool orlprivy 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 .
f if, . ..-I ;❑ •VME14 ...�I1. well :ia . r� IA J,.1.. .. T Gti, _ ! ..1
rrb #U�F,r�'�; 1 '�±, `�11 � .�lrt - p .-.: >', 'r ? 1' rl r��s•1' -r+J
❑ ® Any portion of a cesspool or�privy is within 50 feet of a private water supply well.
I`+ J, ,J r. if i �� '" +: el ;n ir.r' ''P.t i'- ,11 C1r1%1I It:$Id,,I
❑ ® Any portion of a cesspool,or,pnvy is less than 100 feet but greater than 50 feet
from a private water supply well`with no acceptable water quality analysis. [This
Diu .' ;jc r,,W 10 %r71' 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
ant 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-
,
10,000 gpd.
.riCP,`.,lS� �zr j�. Vie;, : iit .':�•�'. i - , , 1 . !� r ha+ r .•,
The system fails.I have determined that one or more of the above failure
❑r1`; i"® " crheria exist as described in'310 CMWi5.303,therefore the system fails. The
:+o�t ;�It+,.,� +,.° I z -•:W. :i:r:'.system,owner,should contact the Board of Health to determine what will be
.,necessary.to correct the,failure. r ; L
l.oa' oo j iC :c ifs. of !.' i s l:t . _"T
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.- ' ' ' at,' !
1, a ,j ::rtFor large systems,:you,rnust indicate either"yes"•on'no"to each of the,following, in addition to the
rr,.,questions in,Section'C.4.•ti, ,„M
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area-IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts . " r . +ice.• !t'r r -
1� Tide 5 Official Inspection Forte:
ill Subsurface Sewage Disposal System Form=Not for Voluntary Assessments • t
l • Y
`fir,-•ter.,+j] 134 Tower Hill Rd
Property Address
Mary Swift
Owner Owner's Name
information is Osterville + ..t
required for every - MA 0265'5 5-12-21 t
page. City/Town r r :`t State Zip Code Date of Inspection
C. Inspection Summary (cost.) �.
If you have answered "yes"to any question in Section C.5 thetsysteir is'considered'a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat;under•Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact'the'appropriate'regional office of the Department.
6.—You must indicate "yes" or"no"for each of the•following for a►1 inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
® Were any of the system'corponents pumped out in the previous two weeks?
t ' ` ® ❑ ' Has the system received normal flows in the previous two week period?
{ El I , 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)
® ❑' g Was,the facility or dwelling inspected for signs of sewage back up?
• e• ; .j t o i-'l,
®' '2❑ Y Was the�site inspected for signs of,break out?
❑ ''' ❑ Were all system components excluding the SAS, located on site?
r .
® ❑ 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,
r r dimensions, depth of liquid,`depth tof sludge and depth of scum?
® ' : Wasthe 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:
® El Existing information. For'example;a,plan atrthe:Board'of Health.
)-.L ftl ®� ❑ I Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
r, r
i I r
r;- .d , � iµ /: '} fir• {I_+ a.• ,c ', ., • : F
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection' Foft- f r
r Subsurface Sewage.Disposal System Form:-Not for Voluntary Assessments
� K
134 Tower Hill Rd
Property Address
Mary Swift
Owner Owner's Name
information is +
Osterville � � 1;- MA 02655 5-12-21v,;,,Pt.�
required for every � w
page. City/Town is ^: ,t.• • ;{- . State Zip Code Date of Inspection ,
- D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3. Number of,bedrooms,(actual): 3
DESIGN flowbased on 310 CMR 15.203 (for:example: 110 gpd x#.of bedrooms): 330
Description:
r
y
Cl� ._ - ► 1 � LV ,itfl,} i{l3'f ..r-t-I -f6,f'�
Number of current residents:
Does residence have a garbage,grinder?f,T 1t =. ha} ❑ Yes ® No
Does residence have a water treatment unit? # ,,, t. t, -z,.},,ri Ptr-V ❑ Yes ® No
If yes,,discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) _ � , :t-� 'x :rw ❑ Yes ® No
Laundry system inspected? - ❑ Yes ® No
Seasonal use? - - ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail: ff; tt
00 rYi r' Uj rrl' t.1j A;: V'j t' !P1? i!'ot jt: '% z::N
Sump pump? �,^n"%'X- .r,2 t ❑ Yes ® No
Last date of occupancy: ,, in„- j50 r,-,quutl'rit,w _,P.L,v-N 5-2021
Date
1
t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection,fofm
N Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments
134 Tower Hill Rd
Property Address
Mary Swift P.;-
Owner Owner's Name r
information is required for every Osterville.' ► MA 0265'5 5-12-21 •
`
page. City/Town ` } State Zip Code Date of Inspection r
D. System Information (cont.) °: •:�
2. Commercial/industrial Flow Conditions: t .1. �.•� _ `+
Type-of Establishment:, .4
Design flow(bated on 310 CMR 15.203): -Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? f ❑ Yes ❑ No
Water meter readings, if available: `
Last date of occupancy/use:
Date
Other(describe below):
3. Pumping Records:
Source of information: Owner---pumped 2 yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
t} : If yes, volume pumped: gallons
How was quantity pumped determined? - -
Reason for pumping: Maintenance
t5insp,doc•rev.17/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 OfficiaHnspection:IFdr'm: �. F
' i�l Subsurface Sewage Disposal System Form Not for Voluntary;Assessments r►• r:ft�
134 Tower Hill Rd tr'"f ;�t,-i i +sc r
Property Address
Mary Swift
Owner Owner's Name R,t;
information is required for every Osterville-t-4. i c1:�L0 IM MA 02655 5-12-21 tc�-:
page. City/Town 7 _,;; r" a . ? State Zip Code Date of Inspection
D. System Information (cont.) ( + i3O") E �.; •_ ,^° :+ '�
4. Type of System: ..: k] i,. 10 f-;• }t. ,;c _.,,..
® Septic tank, distribution box, soil absorption system; : Nc nt as 1
❑ Single cesspool
❑,rr-.�kr. , 6r•Overflow cesspool:, �' �,;t:�� ^.1 �,.,�..tc"� U
❑ 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, to
uV Tight tank.,Attach ia copy�of,the,DEP-approval!". ut>,T" n : ,-t 'N
ir; t;r0
❑ Other(describe): ,fir v)r _{
Approximate'age of all components,,date installed (if known) and source of;information:
1989 "t
Were sewage odors detected',when arriving at the site?.,w- f. r= tt:' J-Pt Yes ® No
;
5. Building Sewaer(locate onsite plan):- io
Depth below grade: c f, .+ ;_,:t r.,r
24"
"feet
",its .?lt if 111.; ri•-t .."`tr .. .1, ►1+Ffif(t:.�t;l• , ';II ,v(t�'-'t`3('�:�1'j;f�l...t 1 ,.(('."Cl1t tri'. t',..+, i �-.(t.;":1P,�
Material'of construction:
.^;..t efyi 115v^'xM1,t~lc G{t i c d'W—
❑ cast iron ®=404PVC►.,re �.,..''�. -:t�.��t tt,«�r •��. ,,,t �,�, w tlt �>�In s
❑'other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts ,: > .. '• ;'
Title 5 Offici_al Inspection flolift
0 Subsurface.-Sewage,Disposal System Form -Not for Voluntary Assessments
134 Tower Hill Rd
Property Address
Mary Swift "w
Owner Owner's Name
information is required for every Osterville MA 02655 5-12-21
page. City/Town , State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan): �
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal; list age: ;_ r v / _.
years
Is age confirmed by a Certificateof Compliance?(attach.a copy of certificate) ❑ Yes ❑ No
Dimensions: ,r . . 1000 gal
611
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 1 �
611
r Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle- 15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee.or,baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,`etc.):'
Tank is in good condition with baffles intalled and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts 1�c Jji_V -(IX, —
JPCIR
Tit I le 5 Oryidi'a I,,, Ins pecti6n" -..;,Fdrm,
Subsurface Sewage:Disposal,System,Form --Not,for Voluntary.Assessments
V5.
T
134 Tower Hill Rd 1'41
Property Address
Mary Swift TV
Owner Owner's Name
information is
required for every 0sterville,S:r t Z. MA 02655 5-12-21
page. City[Town e jt-5,l State Zip Code Date of Inspection
D. System Information (cont.) jroi)
7. Grease Trap (locate on site plan): k
Depth below gride: -A
feet
Material-ofi constructiow.
❑ concrete El metal El fiberglass El polyethylene v 2 El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date
Comments (on pumping.recommendations, inlet and outlet tee or baffle condition, structural integrity,
JK 11-� �A7)f leakage,tl
liquid levels as reiakeflo' outlet'inVert, bvid&nce o eakage, 6tc.):
C
ndul—0.1 P'.8 ej ji I j.r!�rj
.
liq UJJA sd 14: IP07 t t, i ,w)? 'Y it)"-IN" 1p, !U 1)
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:-
Material of construction:
F-1 concrete El metal []-fiberglass ❑ polyethylene El other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 - ' _, -, 1 1, . - I . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
,'. Title 5 Official Iftpection. F&MW � 'I
li Subsurface Sewage Disposal System Form =Not for.Voluntary Assessments r,
i
134 Tower Hill Rd
Property Address
Mary Swift L "A
Owner Owner's Name r
information is required for every Osterville r MA 02655 5-12-21`, I `
page. City/Town _ ," State Zip Code Date of Inspection
D. System Information (cont.) '
r• •� t-.--a*
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No,, '
Alarm level: Alarm in working order:5 : + l Yes ❑ No
• Date of last pumping:
Date -
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached?,0 ru ❑ Yes ❑ No
9: Distribution Box (if present must-be opened)(lo'cat6 on site plan):
• i , ..A'3 i • z •P 14.
Depth of liquid level above outlet invert 0
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.):
Good condition with water at working level and no sign of back-up from pit.
r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16
Commonwealth of Massachusetts
gat Title Official osg�ec$ioh Fo ,
'I Subsurface Sewage.Disposal System Form Not for Voluntary Assessments'�,3t: :...
V5.�
134 Tower Hill Rd t
Property Address
Mary Swift
Owner Owner's Name r +
information is rr ', •: ,:.
required for every_ Osterville v I-Z ?Onco Wl MA 02655 5-12-21,:1 .•
page. City/Town q, " +v:c State Zip Code Date of Inspection
D. System Information (cont.) .; ►g It*; �"Iss rY!a' : �� . ,
10. Pump Chamber(locate on site plan):
..j "+. , .�. e• ,. ,.. ._ , r.' -�,{' .!1F.;�. r.3a •. � �'G .: +r t'tlii��• I„t`! Dfr.if, .? ,F`
Pumps in working order: ' ❑ Yes ❑ No*
�lr? ,r1 +t�tl .l 1 hu
Al .•j arms in working order: ❑ Yes` ❑ No*
+�a.f6l
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a:conditional pass�yri$,"A
11. Soil Absorption System (SAS) (locate on site plan;,excavation not required):•-7
If SAS not located, explain why: j-Vt31 Lot,- • J,-
^6+5 Type: j �,o;'„t _:,�:;rsr{.t;.� ,,.. ,,.�ttr;i' .ji
Qf lli"Ac r r�l •- ti4 1 Is`, ,A n .� C. '� �Ir a +� ng� ;n+�. 1���' 1t.'tl i~, ..1 1-1000 gal
leaching'pits h numb'er: .t4
❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts v
I : Title 5 Official Ihspection- Foft' - , w
iqi Subsurface Sewage Disposal System Form --Not for.Voluntary Assessments .1— r
T, 134 Tower Hill Rd c
Property Address
Mary Swift r•�
Owner Owner's Name ,
information is t
required for every Osterville` MA 02655 5-12-21 '
page. Cityrrown 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.):
Leach pit in good condition with water level and stain line at 40" below top of tank. Inlet enters into
riser.
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 inflow ❑ Yes ❑ No
t! Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): , ;..t .
r-
t ,+
r r t
t5insp.doc-rev.712 612 01 8 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Of'Icaal I nspectaonv F
o rm.,
} +cl Subsurface Sewage Disposal System.Form--Not-fortVoluntary Assessments :r-` "r;
134 Tower Hill Rdr
Property Address
Mary Swift
Owner Owner's Name ar c
information is Osterville r." ';Su r:.; MA 02655 5-12-21•
required for every '
page. City/Town „.r C, 1 a:. State Zip Code Date of Inspection
D. System Information (cont.) .Inn-. nt ''NjA,, jaI.,.-I�
13. Privy (locate on site plan): 4w,S,-V"'�
M i Ici
Matenals"of construction: '' ' {{ rJ[�e,'
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
- • _ - i �W w
° 4 r
T
• r
F
i
t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
w.,
Title 5 Official nspec$ioh For
HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A
134 Tower Hill Rd -
Property Address r
Mary Swift `
Owner Owner's Name w.
information is required for every Osterville MA 02655 5-12-21 -
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
❑ drawing attached separately
r t
f
t
A -3 56- SI, -3
3.
0;
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts �;. r: .,�, . ; _ 'yo ,1,1-,a°, Yc�r
,.y -,:
Title 5 Official. Inspection .For
' ht Subsurface Sewage.Disposal.System,Form Not.forVoluntary;Assessments.°-i-it..',
134 Tower Hill Rd rid 1"N ztiv a'l 's K
Property Address
Mary Swift
Owner Owner's Name j
information is
required for every Ostefville A. MA 02655 5-12-21`:
page. City/Town , u c. •r' :fp State Zip Code Date of Inspection
D. System Information
15. Site Exam: ;� ,,•, ; rya : �n�..J t?r t t.r�.a �e±�, tea73� _
❑ Check Slope ;,�,a, . � i+ : +It ► rP.t7lcl�l ,,�„r rt )I,ti
❑ Surface water r t ,1l,.b; %;;j
❑ Check cellar
❑ Shallow wells w;~ ita ,10,14 ui
Estimated depth to high groundwater:,,;- -v : 20'+^',i 1)6.f),,c�'feet'"
Please indicate all methods used to determine the high ground,water elevation:
❑ Obtained from.system,design plans on-record t,.a ;•4�► : -
b-+. fIf,checked;•date�of,design plan reviewed:.i=,t v;Da.te- _ .:. .. .
"
® Observed site (abutting property/observation hole within)50;feet,of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.:7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
'�g1 To ffo Title 5 OciAl I ns ecteon ,dorm ,
. 1 v
kai Subsurfacel Sewage Disposal System Form -`Not,fortVoluntary Assessments -
r. ' 134 Tower Hill Rd
f .
Property Address '
Mary Swift
Owner Owner's Name
information is Cisterville "� MA 02655 5-12-21
required for every
page. City/Town _ State Zip Code Date of Inspection ,
E. Report Completeness Checklist .
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section. =
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary: ,
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg.-16 or attached
For 15: Explanation of estimated.depth to high groundwater included
ill
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN l7F BfiY�tN�T
�$RIL�A ►`X'8: CC�IVASICE DA' ;
��par�tian p' '8etv�a�4�oc
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1 •Vi�'arnp�1 �tlitr try
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u+1tl�u3�t�eco��ar�iag�tati�t9�
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00
TOWN OF BARNSTABL'E
� q
LOCATION )34 I- x-9- t4 SEWAGE #,�L�
VILLAGE ASSESSOR'S MAP LOT
y 211 -21 L8 .
INSTALLER S NAME & PHONE NO. i�1%�4.- 'f COtiJS
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) pi7 ,_�aaC3 (size).
NO. OF BEDROOMS Z-- PRIVATE WEL' oR PUBLIC pJATER
BUILDER OR OWNER MPa0.' C+viz`.ib.�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No -- -
71
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o y
I
TOWN OF BARNSTABLE
;LOCATION il� -J-OZi-9- 4A SEWAGE
VILLAGE is T-. ASSESSOR'S MAP LOT
'S NAME & PHONE NO. f- itti-I C'00& 1) '21'T � �
i INSTALLER _ .
SEPTIC TANK CAPACITY % 060
�f
LEACHING FACILITY:(,type) (size) � ' S
NO. OF BEDROOMS '7 PRIVATE WEL OR�PUBL�IC-'
ATER
BUILDER OR OWNER C yszLSB --
DATE PERMIT ISSUED: `� a 7
DATE COZII'LIANCE ISSUED:
VARIANCE GRANTED: Yes
71
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a
II`
..; X; ,
4.
No..... .1n.1,.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. ...........I.......
oF. ?.................................g.,.. .......................................
ApplirFa#ion for Disposal Works Tnntrurtitun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Lol�_an Individual Sewage Disposal
System at:
Location-Address or Lot No.
• - 5° c�` ................................................. ._. '.--. ........................................................................
Owner p Address
...........................................................
Installer Address
UType of Building Size Lot............................Sq. feet
.., Dwelling—No. of Bedrooms......... ...........................Expansion Attic ( ) Garbage Grinder ( )
�'4 Other—Type T e of Building No. of ersons____________________________ Showers
YP g ---------------------------• P ( ) — Cafeteria ( )
dOther fixtures ------------------------------------•--•--------------._...----------._._..._._------------------------------•----••------------------•--------...----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid*capacity___,___-:-gallons Length________________ Width................ Diameter...........:.... Depth................
W Disposal Trench—No_ ____________________ Width.............._..... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_---___--___-__-__---.
f Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-._____--____________._.
1:+4 -•-•-----------•••••••••----••----•--•-------•••--------------------------•---------...-•--•-_------........................................................
Description of Soil .' . .......................... :��
j-----------...................................
V ----------•---------------•------------------•------------
W
UNature of Repairs or Alterations—Answer when applicable____- 'k':_.-ati-'V-t@v�L -_ z°Y13f-1<
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of A.- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
a Signed --------•--------- -•---- �Z.
Date
Application Approved By....... --------
..................... Date
Application Disapproved for the following reasons________________________________________________________________________________________________________________
.....-•--•----------•---••----------------------------------•-----------•----------......--------...-----•--•----•--------------------•-----------------------•--•---•-•--------------------------.....-
Date
PermitNo....... .-11 --------------------------- Issued_.......................................................
Date
t
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
: ....... oF. rvsr3...-
Appliration for Biiivaii al lark.6 Tome rurtion rlerattit
Application is hereby made for a Permit to Construct ( ) or Repair (4-<'an Individual Sewage Disposal
System at:
. --.�-S k W t�.........----------------
Location-Address or Lot No.
N\VAc-t � LS�`a Sou ..
....................................................'•-----...-•---•-----'....---'•----'--..------ --...--------•------' ---. -----..--.--.---------------------------------
Owner Address
........................................ = .._ � !-x!.L ...........................................................
Installer Address
UType of Building Size Lot............................Sq. feet
�-� Dwelling—No. of Bedrooms..........
_..._ ...................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___________________________ No. of persons------- Showers —
a yp g p ( ) Cafeteria ( )
Otherfixtures ------------------------------------------------------••----•-'-'------•-----------•------•-•---•--••----•'-'----'. ....-'_...
W Design Flow............................................gallons per person per day. Total daily flow-------_...................................-gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed bY..........-............................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water__:________-_------___-.
r;z� Test Pit No. 2................minutes per inch Depth of Test Pit-_________.___---_-- Depth to ground water..-______________.-____- r`
�+ ----•----------------------------------------------------•....----------_-.._............._..._...---.........................................................
O Description of Soil.........b--.2-�----•----•-----/�� � s r ��r!
r .... ---------------------------------------- '
x ......-----•-•----•-•--•--•-----••-•--•-----------•-'-••'-----••••--•'-•••.----'--------•--••-•-----------=--------'-----' ------
W I
x -- -•-•- •----•.-•--------------•---•----•------------ -----------•-------------•-•••-••--•-----•-----------------......-----•------•-'---•--••--:--------•---..----•-------------'-'--•......--
U Nature of Repairs or Alterations—Answer when applicable_ ____________ --------------------------------
_-------....._../--_---_----------
r 1-r351 � (s� ` ��-�� ��-'! aw 1 C>00 �srt��v..J �ti
•-----•.. .................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
3•-.
the provisions of�'1T r1:.�•:1 . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed •.
=� ------------------• ----
-
1 Date
Application Approved BY
---C--'-�-------�----------1-•---------•---•-•-------------------
a!,
g _ s a" _DateApplication Disapproved for the fo n ..............
.�.........•..-
�!
--------------------------------------------------•------------•'-------------'--•-----------------------------------------------------------•------•------------------------------•----'--.
Date
Permit No........ Issued.......................................................
` _ -r0 --------•-------------•---
Lat.-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( '�:...................0. . �I .2vss:I l3l_1
(9rdif iratr ,af f�utYtpliFattrr
THIS IS TO CERTIFY.That the Individual Sewage Disposal System constructed ( ) or Repaired (- r
by...... =`'---•-..... -------'---------'.................................................•---------------------
_ rysaller n
has been installed in accordance with the provisions of TI T IE: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No---------- .; dated___---------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
L 1
DATE................... --J r 0'7.................................. Inspector------------------- ................................................
THE COMMONWEALTH OF MASSACHUSETTS
c�
BOARD OF HEALTH
�.... �:........................OF...... !� < .........................................
No..... r7,.__�.�.�. FEE....4;1 ... ........ s
Roposal Workv Tomitr on amit
Permission is hereby granted.........�. . !"_�.._.._...`.:c:!5 .. ................................. t
to Construct ( ) or Repair ( an Individual Sewage Di.pos stem S
at No... 1 Y •---•---. mot. Y L--------1=�= {(..............q --------- S ,
Street
as shown on the application for Disposal Works Construction Permit No.__ _.�f__.... Dated..........................................
Bd3�d-et Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS