HomeMy WebLinkAbout0321 TOWER HILL ROAD - Health 321. T6wer Hill Road__ '
Osterville P
Ile- 09g
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
+� — ii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
��% 321 Tower Hill Road
Property Address
Susan Limoncel i
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information Sh # 114 03 j
on the computer, Daniel Hawkins
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return key. Company Name
374 Route 130
m Company Address
Sandwich Ma 02563
City/Town State Zip Code
iilaa (508)477-0653 S114324
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Dan Hawkins ;Digitally signed by Dan Hawkins .
Date:2020.09.0913:38:46 04'00 9-3-2020
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 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.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form--Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑■ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.,
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank'will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
w
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
r
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
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):
F
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water .
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply. `
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Cade Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ O Liquid depth in cesspool is less than 6"below invert or available volume is less
than 112 day flow
❑ EC RegUired pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ a 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.
❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.] ,
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ El 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 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
lip" Commonwealth of Massachusetts
r= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat,or answered"yes—to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes".or"no"for each of the following for all inspections:
Yes No
X Pumping information w r vi h w❑ ❑ p gas provided ded by the owner,occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ O Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
r
ED ❑ 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:
El ❑ Existing information. For example, a plan at the Board of Health.
❑ El Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,YJ 321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3/4 3
Number of bedrooms(design): Number of bedrooms(actual):
NA
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
A permit provided by Board of Health lists 3/4 bedrooms with no design flow shown
on permit.
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Q No
Does residence have a water treatment unit? ❑ Yes 0. No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes '❑ No
Seasonaluse? a ❑ Yes ❑a No
•Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
2018- 52,000gallons 2019-45,000gallons
Sump pump? ❑ Yes ❑■ No
• _ current
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
J '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
L Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code 'Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Owner- last pumped 1 year ago
Source of information:
Was system pumped as part of the inspection? El Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
e
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 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:
1998 per permit
Were sewage odors detected when arriving at the site? ❑'Yes X No
5. Building Sewer(locate on site plan):
2,8,;
Depth below grade: feet
Material of construction:
❑ cast iron 9 40 PVC ❑other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every t
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1,8„
Depth below grade: 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
1
Dimensions: 500gallons
4"
Sludge depth:
32"
Distance from top of sludge to bottom of outlet tee or baffle
2 It
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
15"
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank does not
have heavy solids present but should be pumped as the are many baby wipes
present. Wipes should not be flushed.
15insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� J 321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is required for every Osterville Ma 02655 9-3-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0'r
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.J 321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ..
10. 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.):
NA
* If pumps or alarms are not in working order,system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(2)500 gallon chambers
E leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches f 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
i
c Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli -
Owner Owner's Name
information is
required for every Osterville Ma 02655 9-3-2020
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.):
The SAS was in working order at the time of inspection. Leaching was 1/2 full when
viewed.
12. Cesspools
s(cesspool must be pumped as part of ins
pection)ection)(locate on site plan):
NA
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction µ
Indication of groundwater inflow - ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of,18
i
IL—
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (Cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
h
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
321 Tower Hill Road `
u
Property Address
Susan Linnoncelli
Owner Owner's Name
information is required for every Osterville Ma 02655 9-3-2020
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
❑ drawing attached separately
f
i
Front
A B
5
A2-W 82.1't
A3.2r B3.1W
4
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑■ Check Slope
❑■ Surface water
❑■ Check cellar
❑■ Shallow wells
No GW @12'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation: .
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Bottom of SAS elevation was determined and transfered to a low area showing
ground water is greater than 12' below grade. Bottom of SAS is >4' above water.
r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15insp.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
321 Tower Hill Road
Property Address
Susan Limoncelli
Owner Owner's Name
information is Osterville Ma 02655 9-3-2020
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
t5insp.doc•rev.7/26/2018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 -
L
TOWN OF BARNSTABLE
SEWAGE #
VILLAGE �� '�� �SS ASSESSOR'S MAP & LOT
INSTALLER'S NANS&PHONE NO.
SEPTIC TANK CAPACITY n�,
w
l
LEACHING FACILITY: (tyre) (size, /1
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leach* Facility.If any we ds 'st
with*n 300 feet of c g fa, Feet
I ' t
Furnished by
o
TOWN OF BARNSTABLE
LOCATION LOU., &A— dJ P/ SEWAGE # L6
VILLAGE ASSESSOR'S MAP &LOT/� S '6 f�
INSTALLER'S NAME&PHONE NO. Rb S�-��
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)e t'yt (size)
NO.OF BEDROOMS _�` A/
BUILDER OR OWNER A 3
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Fail tY Feet
J g�
Private Water Supply Well and Leaching Facility (If any wells a -st
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
_�v � z
.�
µ wt �.
a Y ._j ..
}
_..... '�� i -
No. / o Fee $5 0 . 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Mis pogal *p5tem Cougtruction Permit
Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) EJ Complete System ❑Individual Components
Location Address or Lot No. 321 Tower Hill Rd Owner's Name,Address and Tel.No. 4 2 8—6.6 3 3
Assessor'sMap/Parcel Osterville, MA Brenda Ajbour 321 Tower Hill R
Centerville, MA 02632
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
WE Robinson Septic Service
PO Box 1089 , Centerville, MA 026 2
Type of Building:
Dwelling No.of Bedrooms 3/4 Lot Size sq.ft. Garbage Grinder(not
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 septic system consisting
of 1500q tank, D-box, and two 500-gallon precast leach chambers.
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 Certifi-
cate of Compliance has been isys ed b B3oilfd of Healt .
Signed Z� i t Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. O o - Fee $5 0.0 0 /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. ✓f
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPfication for
�' gogaf *poem �Congtruction hermit
Application for a Permit to Construct( )Repair PCX)Upgrade( )Abandon( ) []Complete System ❑Individual Components
Location Address or Lot No. 321 Tower Hill Rd Owner's Name,Address and Tel.No. 4 2 8—6 6 3 3
Assessor's Map/Parcel Caterville, MA` Brenda, Ajbour 321 Tower Hill R
Centerville, MA 2632
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
WE Robinson Septic Service
PO Box 1089, Centerville, MA 026 2
Type of Building:
Dwelling No.of Bedrooms 3/4 Lot Size ---- sq.ft. Garbage Grinder(ng
Other Type of Building hTo.�f'�so s v Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 septic system dorisi,st`iing
of 1500g tank, D-box, and two 500-gallon preeast leach chambers.
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 Ynd,n?t to place the system in operation until a Certifi-
cate of Compliance has been issged by t ' B d of Healt l
Signed � I I Date
Application Approved by cr' Date y' f
Application Disapproved for the following reasons
Permit No. Date Issued
,— ------- _-- -------------- —
���THE G.Q�MMO.NM(6AtiLTH-`O'F MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Aj hour Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( x�Upgraded( )
Abandoned( )by
at 321 Tower Hill Rd, Osterville has been constructed in acco dance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �_r"ZOJ dated %'3- 9
Installer W E Robinson Septic Sry Designer
The issuance of this permit shall no,t,byonstrued as a guarantee that the system will function as designed.
Dated - 1 "/ Inspector
No. � _ �0�•- ----------------------=---Fee $50.00
THE COMMONWEALTH OF MASSACHUSETTS L
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
g+bour
igpogaf *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(x�Upgrade( )Abandon( )
System located at 321 Tower Hill Rd
Osterville, MA
Installer: W E RobinsonSeptic Service
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: �/�3-5 Approved by 'A' ['
,
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E Robinson, Sr ,hereby certify that the application for disposal works
construction permit signed by me dated g , concerning the
property located at 321 Tower Hill Road Osterville, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
f (Zo � L
o
TOWN OF BARNSTABLE
LOCATION l l o:.v C� �l• �' SEWAGE #
VT1:LAE ✓ ASSESSOR'S MAP&LOT Jf $'d
INS'TALLER'S.NAME'&PHONE NO. ti 56 A— 'Z ')
SEPTIC TANK CAPACITY'.
LEACFENG.FACILITY: (type)a Gam, �► /�l.'� (size) fl 3 a
NO OF BEDROOMS _ /
BMDER OR OWNER A SaU Z
PEI MTTDATE: y_3. 1 COMPLIANCE DATE: CI`�•Z
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom'of Leaching. l ty•. Feet
Prvate:Water Supply Well and Leaching Facility.• (If.any wells 'st
:on'site or within.200 feet of leaching facility)' Feet
Edge of Wetland.and Leaching Facility'(If any wetlands' st
.within 300 feet of leaching facility) Feet
Furnished by
J.
1
r
j J'
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
9� ��� Public Health Division
�o ILIA•+p
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
March 28, 2007
Attn: Comm Fire
Health Inspector Timothy B. O'Connell conducted a rental inspection in accordance with
Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary
Code, 105 CMR 410.482, the Health Department is required to notify the Fire
Department if there is a smoke detector violation, or possible smoke detector violation.
The following property had possible smoke detector(and\or CO detector)violation(s):
321 Tower Hill Road,Assessors Map-Parcel: (118-098):
No CO detector withi ome.
Timoth . O'Connell-Health Inspector
Q:\Order letterMousing violations\Rental ordinanceUire ViolationsTIRE TEMPLATE.doc
k�
-� COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
DEPARTMENT OF ENVIRONMENTAL.PROTECTION
TITLE 5
OFFICIAL, INSPECTIONYORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM.FORM
PART A
CERTIFICATION
Property Address. :
Owner's Name:
Owner's Addre s
~ �
Date of Ins ection: C1la r.
P i
Name,of lease_print) >`
i
Company Name. �: e�7,� t 9
Mailing Address : ell A � :� i -,/_
960 crs#
✓
Telephone Number': r � �la�f
y.
CERTIFICATION STATEMENT ':-' 3.
1 certify that I have'personally inspected the sewage disposal system,at this address and that the linformation reported
below is*rue,accurate and complete as of the time of the inspection..The inspection was performed based on mj
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DE.P
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:',
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Inspector's Signature: 14
Date: �'( �
The system inspector shall submit aycopy of this inspection report_ to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the systein is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority. .
Notes and Comment4 & A /'` '�Z� I2�' �-x 1)9te
****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.
Title,,5 Inspect,ion Torm 6115/2000. page d
Page 2 of l l ..
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DTSPO.SAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION (continued)
Property P Y Address: cotv
a
Owner..
.C.+
Date
ection: J
P �--
T.
Inspection Summary: Check A,B,C,D or E/ALL
WAYS complete all of Section D
A. 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:
B. System Conditionally
s m
y ovally Passes:
One or more system components as described in the"Conditional Pass" Psection need to be re laced.or
repaired.The system, upon completion of the replacement or repair;'as approved by the Board of Health;will pass.
Answer yes,no or not determined(Y,N;ND)in the for the following statements:If"not determined"please
explain.
The septic tank is metal arid'over 20 years old* or the septic tank(whether metal or not)is structurally:
unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available. .
ND explain:-
Observation of sewage backup or break out or high static water level in the distribution box due to broken or.
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approyal of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
J:
I
Page 3 of l l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPO.SAL SYSTEM INSPECTIONFORM
PART A
CERTIFICATION(continued)
Proper Address:
Owner:
Date of h ection:
C. Further.Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
h system.is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a borderin;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,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the.SAS is within 100 feet of .
surface water supply or tributary to a surface water supply:
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has 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 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,provided that no other . .
failure criteria are triggered. A copy of the analysis must.be attached to this form.
3. Other:
3
r
Page-4 of 1 I
OFFICIAL INSPECTION FORM_=.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE`DISPOSAL 8.-VSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner.
Date o I spection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each.o
y f the.following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool
Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or
Clogged SAS or cesspool
i/ Static liquid level in the distribution box above.outlet invert due.to an overloaded or clogged SAS or
f cesspool
Liquid depth in cesspool is less.than 6"below invert or available volume is less than %day flow
Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number
of times u p mped
Any portion of the.SAS,cesspool or privy is below high.ground water elevation.
Any portion of cesspool or rivy 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.I of a.public well.
Any portion of a cesspool or privy is within 50 feet of d,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 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, provided that no other failure;criteria
are triggered.A copy of the analysis.must be attached to this form.]
. (Yes/No)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, r
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
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)
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
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
g system has failed.The owner or operator of any large system considered,a
significant threat under Section t E or failed under Sectio
n D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 1 1
OFFICIAL INSPECTION..FORM—NOT,FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWGE DISPOSAL SYSTEM INSPECTION. FORM
PART B
CHECKLIST
Property Address:
Owner.
Date of ection:
Check if the following have been done.You must indicate"ye::";or"no"as to each of the followine:
Ye:Yes �No t .• �. - -
— 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
tr Has the system received,normal flows in the previous two`week period
L. 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
I
_ Was the site inspected for signs g ns of break out? .
P g
_jZ/_ 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
_il_ P . P P
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:
Yes no
a
xi ti 'n example,
E s n � formation: Fora plan at the-$oard of Health
Determined in the field(if any of the failure criteria Felated to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J.
5
Page 6 of 11.
OFFICIAL INSPECTION:FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM.INFORMATION
Property Address:
Owner. '
Date;o pection - o
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design): 4_ Number of bedrooms(actual):
DESIGN flow based on 310 CMP, 15.203 (for example: 11.0 gpd x.#of bedrooms):
Number of current residents: V
Does.residence have a garbage grinder(yes or no): ?
Is laundry on a separate sewage system.(yes r no.)� [if yes separate inspection required]
Laundry system inspected(yes o no): �l 0
Seasonal use:(yes or no):1✓� G�J �
Water meter readings, if available(last 2 years usage (gpd)): �2 1A(V
Sump pump :
P(yes or no)
Last date of occu anc
COMMERCIAL/INDUSTRIAL f\/d
Type of establishment:
Design flow(based on 310 CMR 1.5.203): gpd
Basis of design flow(seats/persons/sgfft,etc):
Grease trap present(yes or no):_
Industrial waste holding tank;present(yes or no):
Non-sanitary waste discharged to the Title 5 system.(yes or no);
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records ;
Source of information: ��._.
Was system pumped"as'part of the i spectio _ es or no):-_ ;T,,.
If yes, volume pumped: gallons--How was.quantity pumped determined?
0
Reason for pum mbp .
TY,PFOF SYSTEM
L 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).
—Tight tank _Attach a copy of the DEP approval
Other(describe):
A ximate age of ali�component�s, dat installed(if known)and source of information`.
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of 17
OFFICIAL INSPECTION FORM—NOT FORYOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM.INSPECTION FORM
PART C .
SYSTEM.-INFORMATION(continued)
Property Address:
IL-"
Owner:
Date of l ection: ` .
BUILDING SEWER(locate on site plan) VO
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANK T C locate on site plan) '
,
—( P ) .
Depth below Grade: /
Material of construction:��concrete_metal—fiberglass polyethylene „
_other(expfain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes,-or no): (attach a copy of
certificate)
Dimensions:
Sludge depth: 11
Distance from top of sludge to bottom of outlet tee or baffle: .
Scum thickness: C.v
Distance from top of scum to top of outlet tee or baffle: '
rr ,
Distance from bottom of scum to bo of outlet tee or baffle: %!
How were dimensions determined:
Comments(on pumping recommeitations,hiet and outlet tee_or baffle condition, structural integrity, liquid levels
belated to outlet invert, evi e ce of lea age, etc.):
W.
�/,Xj M&AMAJ (\,9z A---V, e
��i�il�/ . ! ��� �yC�°--C-(.:fit.-a °J�2E.���/_, �'�C�r!•G -Z./�C�./�,.
GREASE TRAP:�t�(locate on site plan) d � �
Depth below grader
Material of construction:._concrete metal fiberglass _polyethylene_other
• (explain): — —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: ,
Distance.from bottom of scum to bottom'of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 1.1
OFFICIAL INSPECTION FORM_NOT,FOR:YOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART Q SYSTEM
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of ection: ��> �00
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locat.e on.site plan)
Depth below grade:
Material of construction': concrete metal fiberglass_polyethylene other(explain);.
Dimensions:'
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:�ifpresent must be opened)(locate on site.plan)
Depth of liquid level above outlet invert: C../"!'. ,/)(i; l�?
Comments(note if box is level and distribution to outletVqual, any evidence of solids carryover, any evidence of
,-I kace intopor out of box,�ete
PUMP CHAMBER./: V� (locate on site lan)
p ,
Pumps in working order,(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
1
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
PART C
SYSTEM INFORMATION(continued)
Property Address:. _T0
Ow ar..
Date spection f'` 69
SOIL ABSORPTION SYSTEM (SAS): Alocate on site plan,excavation not required)
If SAS not located explain why:
Type
lea mg pits,number:_
caching chambers,number:
Teaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
_.innovative/alternati.ve system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, leve).of ponding, damp soil,condition of vegetation,
etc.)•t _
:> f �
Ii 11 J -
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 or no): .
Comments.(note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
' PRIVY: (W locate on siteplan) w
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc,):
Page IO.of 1.1
OFFICIAL INSPECTION_TORM* .NOT FO.R VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE°DISPOSAL SYSTIE SPECTION FORM
PART C
SYSTEMINFORMATION(continued)
Property Address: =.�i� ��~�� ,��,,� ,��•�
Owuer: .�te°�
Date c spection: ";J 71
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch,of the sewage disposal,system including ties to at least two permanent reference Jandinarks or
benchmarks. Locate all wells within 100 feet:Locate.where public water supply enters the building.
In - �
son
o
Lff
Page 11 of 1 I
-OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
.Owner:
Date of I s ectibn: 1 �
SITE EXAM .
Slope .Y
Surface water
Check cellar
Shallow wells . . ,
Estimated depth to ground water 1-0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site (abutting property/observation hole within If 0.feet of SAS)
Checked with local Board of Health-explain:
/Checked with.local excavators, installers-(attach documentation)
d✓ Accessed USGS database-explain: .
You must describe how you established the high ground water elevation:
A
Permit Number: Date:
Completed by;
HIGH GROUND-WATER LEVEL COMPUTATION
�,�
Site Location: .z / G � �. `G� s Lot No.
Owner: Address.
Contractor: � '��` .,ViI67' 69W,5 Address:
Notes: - —
STEP 1 Measure depth to water table
#t. .......to nearest 1/10 :........ Date �1 1
......... ......... ......... :........ . d
month/day/Year
STEP 2 Using Water-Level Range Zone.
and Index Well Map locate
site and determine
OA :Appropr.iate mtlex;well
OB Water level range zone ................................................
r
STEP 3 'Using monthly:report''Current
WaterResources Conditions
deterrri ne current depth to
`water level for index well : �!
month/year
STEP 4 Using Table of:Water'level Adjustments
:for index well-(STEP.-:2A),'.cur-rent-depth
to Water level-for index well-(STEP 3);
and water level zone (STEP 2B)
' determine water level,adlustment .......................................................................................:.. s
STEP 5 Estimate depth to high water'
by subtracting.the.water
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ..: t /
Figure 13.-Reproducible computation form.
1
5
/�7.o -- �
�r
• r
D ATE: 3/ 18/02
-----------
PROPERTY ADDRESS;
321 Tower Hill Road
-- ---- ----Mass __-_-_--
02655
------------------------
On the above date, I se Inspected the septic stem at the above address.
P P
This system consists of .the following:
1 . 1-1500 gallon septic tank . 3� I
2 . 1-Distribution box . J
3 .
Based on my inspection, I certify the following conditlons: CEIVE®
4 . This is a title five septic system .
5 . The septic system is in proper working order APR 0 22002
at the present time .
6 . There is only 6" of waste water in _chambers .
• "TOWN OF BARNSTABLE
HEALTH DEPT.
SIGNATURE:1
Name:_J Macomber Jr-----__
Company : Joseph-P . Macomber & Son , Inc .
Address : Box 66 - --- '
Centerville , Ma . 02632-0066•
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MA60MBER & SON, INC.
Tan ks•Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT'OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A _
CERTIFICATION
Property Address: 321 Tower Hill Road'
Osterville ,Mass .
Owner's Name: Karin Frangipani w.
Owner's Address:Same
Date of Inspection:
Name of Inspector: (please print) Joseph P ,Macomber Jr, .
Company Name: J. P.Macom er & Son Inc . '
Mailing Address: Box 66
. 02632
Telephone Number:508-775-33 8
CERTIFICATION STATEMENT
1 certify that 1 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
Needs Further Evaluation by the Local Approving Authority,
+ Fail
Inspector's Signature: t Date:
The system inspector shall s mit a"
of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
"*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. ;
Title 5 Inspection Form 6/15/2000 page I
i
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A ,
CERTIFICATION (continued)
Property Address: 3 21 Tower Hill R o a"d
Ostervi e ;Mass .
Owner:Karin Frangipani
Date of Inspection: 3 18 0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
-A. System Passes:
,VO I have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or�irt 3T6� R 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in "proper working order at the " .
present time .
B. System Conditionally Passes: '
One or more system components'as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board,of Health, will pass.,
Answer yes,no or not determined(Y,N,ND) in the for the following statements.If"not determined"please
explain.
416 The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is`structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
IV Observation of sewage backup or break out or high'static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health)
.broken pipe(s)are replaced.
obstruction is removed' '
distribution box is leveled or replaced
ND explain: t .
X1 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 e''
obstruction is removed '
ND explain: ,. L
2
I
Page 3 of 1 1 �..
OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY"ASSESS MENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _ ;
'CERTIFICATION(continued)
Property Address: 321 Tower Hill Road '
stervi e ,Mass b-
Owner: Karin. Frangipani a"4
Date of Inspection: 3 18702
.F. 2 .
C. Further Evaluation is Required by the Board of Health
A10 Conditions exist which require further evaluation by'the"Board of Health in order to determine if the system
is failing to protect public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect.public health,safety,and the environment:
A)d 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 marshF.
-'
a
7
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:
/Ud The system has a septic tank and soil absorption�system(SAS)and the SAS is within 100 feet of -
surface water supply or tributary to a surface water supply.
�d The system has a septic tank and SASand the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within.50 feet of a private water supply welt.
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"coliform'
bacteria and volatile organic compounds indicates thafthe 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,provided that no other
failure criteria are triggered:'A copy of the analysis must be attached to this,form. "µ
,
3. Other:
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 321 Tower Hill Road
stervi e , ass .
Owner: Karin Frangipani
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ t/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box 4ove utlet invert due to an overloaded or clogged SAS or
J cesspool
j Liquid depth in•oe%j" is less than 6"below invert or available volume is less than '/,day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
— of times pumped Q
ky portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
]�
�Any
y portion of a cesspool or privy is within a Zone 1 of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.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 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, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
4)0 (Yes/No)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•
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)
yes n�o/ '
�/ 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 11 of a public water supply well
If you have answered"yes"to any question'in Section E the system is considered a significant threat,or answered.
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
f
Page 5 of I I
OFFICIAL INSPECTION FORM-- NOT FOR VOLUNTARY•ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 321 Tower Hill Road '
0sterville .Mass .
Owner1arin Fran i ani
Date of Inspection: 3 18 02 i
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes � ,, . ' • . >
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 pan of this inspection?
Were as built plans of the system obtained andjexamined? (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 breakout?.
Were all system components, luding the SAS, located on site ?
1_ 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 infotmaiion,on the proper
maintenance of subsurface sewage disposal systems ?
- • V
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
y _ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of,distance
is unacceptable) (310 CMR 15.302(3)(b))
5
'
Page 6 of 1 I ,
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 321 Tower Hill Road
stervi e ,Mass .
Owner:Karin Frangipani
Date of Inspection: 3 18 0 2
FLOW CONDITIONS.
RESIDENTIAL
Number of bedrooms(design):--4— Number of bedrooms(actual):
DESIGN flow based on 310 CMlt 15.203 for example: 110 g d x# of bedrooms):
Number of current residents: j
Does residence have a garbage grinder(yes or no): !UD
Is laundry on a separate sewage system ( es or no):4)d [if yes separate inspection required]
Laundry system inspected(yes or no): 75
Seasonal use: (yes or no): A�17
Water meter readings, if available(last 2 years usage(gpd)): 2000-43 , 000 gallons=117 . 81GPD
Sump pump(yes or no):)6 — ., ga11'ons=169. 87GPD
Last date of occupancy: -
w.
COMMERCIAL/WDUSTRIAL
Type of establishment: Jt)4
Design flow(based on 310 CMR 15.203): A14 gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): 8&4
Industrial waste holding tank present(yes or no):,�i4 `
Non-sanitary waste discharged to the Title 5 system(yes or no): .Q
Water meter readings, if available: paid
Last date of occupancy/use:_4 4
OTHER(describe): AR
GENERAL INFORMATION
Pumping Records )-
Source of information: irle �4UTAI� o�P�
Was system pumped as part of the inspection(yes or no):. °J
If yes, volume pumped: ('l gallons-- How was quantity pumped determined?
Reason for pumping`
TYPY OF SYSTEM
_ZSeptic tank,distribution box,soil absorption system
AIQ Single cesspool
40 Overflow cesspool
401 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)
Tight tank 4,2_"Attach a copy of the DEP approval
A4)Other(describe):
Approximate age of all com a is date ' stalled (if known)and source f information:
Were sewage odors detected when arriving at the site(yes or no)Ad
6
Page 7 of 1 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM'
PART C '
SYSTEM INFORMATION(continued). '
Property Address: 321 Tower Hill Road
Osterville ,Mass . ,
Owner: Karin Frangipani
Date of Inspection: 3/18/0 2
BUILDING SEWER(locate on site plan)
Depth below grade.-
Materials of construction: cast iron . z,, PVC Z/Oother(explain): 91.4
Distance from private water supply well or suction line: 1& `?-
Comments(on condition of joints,venting, evidence of leakage,etc.):
Joints appear tight . No evidence of leakage . System 'is vented
through the house vents :
SEPTIC TANK: Z(locate on site plan)f'`✓��'R1 f
Depth below grade:
Material of construction: IJconcrete metal,&fiberglassl/polyethylene
�ther(explain) /c.OF
If tank is metal list age:,dW Is age confirmed by a Certificate of Compliance(yes or no):41(attach a copy of
certificate)
Dimensions:
Sludge depth: .
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: -
Distance from top of scum to top of outlet tee or baffle: /
Distance from bottom of scum to bottoyym, of outlet tee or baffle:
How were dimensions determined: ��
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage, etc.): • t .
Pump the septic tank every 2-3 years . Inlet & outlet tees
mare in place. The tank is structurally sound and' shows no
evidence of leakage . The liquid level at the outlet invert
is fifty one inches .
GREASE TRAP,ef2qfJlocate on site plan) '
Depth below grade:
Material of construction:�concrete mmetal7I�kfiberglass fdpolyethylene lkother "
(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: //0
Date of last pumping:1i4 ;
Comments(on pumping recommendations, Net and outlet tee or baffle condition, structural integrity, liquid,levels
as related to outlet invert,evidence of leakage;etc.):
t
Grease trap is . not present :
7
Page 8 of I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 321 Tower Hill Road
stervi e , ass .
Owner:Karin Frangipani
Date of Inspection: 3/18/0 2
TIGHT or HOLDING TANKWaLe-(tank must be pumped at time of inspect i on)(]ocate on site plan)
Depth below grade: WA
Material of construction:A&concrete,Zi�metal AAfiberglass 14 polyethylene f other(explain):
Dimensions: A114
Capacity: -/ gallons
Design Flow: 1414 gallons/day
Alarm present(yes or no):
Alarm level: AM Alarm in working order(yes or no): 4,,W
Date of last pumping: A),4
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present .
DISTRIBUTION BOX:2(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: te
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.):
Di ,qt-ribnt-ion box haq one No evidence of solids
carry over . No evidence of leakage into or out of the box .
PUMP CHAMBER4 e.(locate on site plan.)
Pumps in working order(yes or no): Al 4
Alarms in working order(yes or no): NA
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump chamber is not . present .
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:321 Tower Hill Road
Osterville ,Mass . ` _ •
Owner: Karin Frangipani
Date of Inspection: 3/18/0 2 "
SOIL ABSORPTION SYSTEM (SAS): Zocate on site plan,excavation not required)
2-500 gallon chambers spaced . 30 ' X11 ' X2 '
If SAS not located explain why:
Located see page 10
Type
aching pits, number:
leaching chambers, number. 7 Y�
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number,dimen ions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:///.fe &0
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to sandy loam to medium fine sand . No signs of ,
hydraulic failure or ponding . Soils are dry . Vegetation is
normal .Waste water is 18" below the invert pipe .
CESSPOOLSt"cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer: ,
Depth of scum laver: _ t
Dimensions of cesspool: rF i
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present .
PRIVY (locate on site plan)
Materials of construction: /dig
Dimensions: A19 -
Depth of solids: AZ .
T Comments(note condition of soil, signs of hydraulic failure,' level of ponding,condition of vegetation, etc.):
Privy is not present .
l
Page so of I I
OFFICLAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-_` SYSTEM INFORMATION (continued)
ProperryAddress- 32.1 Tower Hill Road
stervi e , ass .
Owoer. Karin Fran ipani
Date of Inspcetioo: 3 18 02
SKETCH OF SEWAGE DISPOSAL SYSTEM }
Provide a sketch or the sewage disposal system including tics to at least rwo permanent reference landmarks or
benchmarks. Locate all wells within Ioo feet. Locate where public water supply enters the building.
•
i
I z
10
Page I I of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I ' PART C
SYSTEM INFORMATION (continued)
Property Address: 321 Tower Hill Road
stervi le , mass .
Owner: Karin Frangi ani
Date of Inspection: 3 18 02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
,Obtained from s stem desi plans on record - If checked, date of design plan reviewed: '��
bserved site(abuning propert&bservation hole within 150 feet of AS)n
C cked with local Board of Health explain:O ?�i¢J:�/d� S �si�T L
cked with local excavators, install e (an ch documentation)
Accessed USGS database-explain: /,1�•�.
You must describe how you established the high ground water elevation:.
Used ; Gaherty & Miller Model 12/16/94 Groundwater elevation above
sea level .
Used : USES nhservation wP11 rjata j,inP 1QQ9
Used : USG Annual TEPO""6bdf Srnii n d 1Jatar- Ajevat jQpr' for- v3-ppe ed
92-000-01 Plate #2
Leaching
Pit b. :cc(
Groundwater: PC Below Bottom of Pit High Groundwater Adjustment� stmcnt 1.8 ft per FrimP to Method
- Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwatcrtable is
feet.
1RTTn R'I7r-r1r rn nrr•nmrsr-e.rtrarmmn�rr!rmn+ss�s.nm tRrR7riTs�-�iTORrrt+ rrri-rr.�-nr-:.,_-.r-...
TOWN OF Barnstable BOARD OF 11EALTII
SUIlSUIIFACR SEWAGE DISPOSAL SY3TF,M I88PFCTIOU FORM - PART D.;.- CERTIFICATION I!
•••T••t•T••.•.•.—T.tif.^.�T TT.1'R.?.TITiT.T[TTf]T,'Tl'1�1.-I�SRTtiT1T'TRRITCP{►1/7�lCRT'�f'RT't ism r.�rrr•r.--,•—..A
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 321 Tower Hill Road- Osterville ,Mass , . '
ASSESSORS MAP, BLOCK AND PARCEL V
OWNER' s NAME Karin Frangipani
PART U - CERTIFICA TION r
NAME OF INSPECTOR Joseph P.Macomber Jr
COMPANY NAME J.P.Macomber & Son Incje. ,
COMPANY ADDRESS Box 66 - Centerville ,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 790 _ 1578
CERTIFICATION STATEMENT R
I certify that I have personally inspeeted ' the sewage disposaj system at
this address and that the information reported is true , accurate , and
omplete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one;
System PASSED.
The inspection which I have conducted has not found any- information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 Any failure
criteria not evaluated are as stated 'in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con ticted has found that the system fails to
protect the ilublic health and the environment in accordance with Title
6 , 3.10 CMR 15 . 303 , .and as specifically noted on PART C - FAILURE
CRITERIA of this inspection f rm ,
Inspector Signature Date
.�.>�•�,--Wiz. .__ _ _
copy of this a ification must be provided to the OWNER,• the BUYER
Ond
where applicable) and the 130ARD OF HEALTH,
* It the inspection FAILED, the owner or*"operator shall upgrade system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 15 . 305 .
partd .doc
t
�a•I.I.nT -nt•r��•a-r�,rnrmr•nmvnr-nni'sR.T1I^.T+r�ft+rR'mnn enTwv l��fRwT t T7*n-.rev:•rr-:,.-.,r-...
TOWN OF Barnstable BOARD OF 11EALT11
SUBSURFACE SEWAGE-01SPOSAL SYSTEM INSPECTION FORM - 'PART D.- CENTIFICATION I
•••Tl1�T••••,•f-T.117,-.�Ta"ITT"111 T.TlITT.1lTTfTT.T�'r!'I."11T,1'�7nnCrTIRRVY►Rt�TR�!A'1�7 ttR1 •.TII•T'1'�•�. .�..A
-TYPE OR PRINT CLEARLY- '
PROPERTY INSPECTED
STREET ADDRES$ 321 Tower Hill Road Osterville,Mass , . '
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Karin Frangipani
PART U - CERTIFICATION
NAME OF INSPECTOR Joseph P . Macomber Jr ..
COMPANY NAME J . P.Macomber & Son Incjr. ,
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Strvvt Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 -'3338 . FAX (508 790 1578
CERTIFICATION STATEMENT .. , .
I certify that I havye . personally 'inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and 'repair are consistent
with my training and experience in the proper furiction-_ and maintenance -of on-
site sewage disposal systems , ,
Check one ,
System PASSEDh A
y ,
The inspection which I have conducted has not found- any information-
which indicates that the system fails to adequately protect. public '
healLh or Lhe. environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILEll*
The inspection which I have con Lcted has found that. ;the' system fails to
Protect the publ'ic: health and the environment in accordance with Title
5 , 3.10 CMR 15,1303 , and as specifically noted on PART C FAILURE
CRITERIA of this inspection f rm .
Inspector Signature Date A -1 .
and copy of this .ification must be provided to -the OWNER, the IIUYER
here applicable ) and the r30ARD OF HEALTH.
* If the inspection FAILED , the owner or "operator shall upgrade ayetem within one year of the date of the inspection , unless allowed or required- -
otherwise
as provided in 3.10 ChIR 16 , 305 .
partd .doc