HomeMy WebLinkAbout0012 VERMEER COURT - Health 4`
12 VERMEER COURT
Osterville, MA
A
Y
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t,
u
C,
12 Vermeer Court
Property Address r ti
Jeffrey&Carole Darelius
Owner Owner's Name Y
information is
required for every Osterville 01/ MA 02655 08-16-2019 -
page. City/Town State' Zip Code Date of Inspection ^4
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
Co
� Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
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 m training and experience in the proper function
P p Y 9 P P P
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
08-18-2019 -'�--
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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
L
Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
12 Vermeer Court
Property Address
Jeffrey &Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. Cityrrown 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:
This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding a precast
leaching pit with stone. At the time of the inspection there were no visible failure criteria found.
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):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I_
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Vermeer Court
Property Address
Jeffrey& Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Vermeer Court
Property Address
Jeffrey &Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
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
❑ ® 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
Commonwealth of Massachusetts
a Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c� 4 12 Vermeer Court
Property Address
Jeffrey &Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of,Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 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
1p Title 5 Official Inspection Form
11 F` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. Cityfrown 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 a0/inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the.SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is Osterville MA 02655 08-16-2019
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
GPD
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
In 2018 27,000 gallons were used and in 2017 24,000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: a few weeks ago
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., 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:
Source of information:
Was system pumped as part of the inspection? ❑ 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
Commonwealth of Massachusetts
:. p Title 5 Official Inspection Form
<I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Vermeer Court
V�
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1983
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
"
Depth below grade: 21
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
( p )
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
standard H-10 10'00 gallon
Sludge depth: 3„
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness 2„
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?
sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of the inspection the liquid level was at working level
and the baffle was in place.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass El polyethylene 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 of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 12 Vermeer Court
Property Address
Jeffrey &Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
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):
Depth of liquid level above outlet invert
01.
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
jo Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Vermeer Court
Property Address
Jeffrey& Carole Darelius
Owner
Owner's Name
information is required for every Osterville MA 02655 08-16-2019
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.):
* 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: one
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
f ,
Commonwealth of Massachusetts
p Title 5 Official Inspection Fora
ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Vermeer Court
Property Address
Jeffrey& Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
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.):
At the time of the inspection the leaching pit was dry. Note the pipe enterers the leaching pit a lower
than normal hight.
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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
I.? Title 5 Official Inspection Form
�11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ 12 Vermeer Court
Property Address
Jeffrey&Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. CitylTown 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
�S ki,
W v11J
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
I
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V. 12 Vermeer Court
Property Address
Jeffrey& Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 14 plus feet
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:
I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
12 Vermeer Court
Property Address
Jeffrey &Carole Darelius
Owner Owner's Name
information is required for every Osterville MA 02655 08-16-2019
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
AP
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE
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Separation Distance Between the: .
Maximum Adjusted Gfoundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 fat of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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e A unique Identifier for your mailpiece
a A record of delivery kept by the F ostal Service for two years
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e Certif led Mail is notavailable for any class of international mail.
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fee.Endorse mailpiece Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
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o If a postmark on the Certified Mail receipt Is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed;detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present It when making an inquiry.
PS Form 3800.August 2006(Reverse)PSN 7530-02-000.9047
•MPLEiE THIS SiCTION . ON DELIVERY
■ Complete items 1,2,and 3.AIso complete A. Signature
item 4 if Restricted Delivery is desired. ❑Agent
0 Print your name and address on the reverse X ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
® Attach this card to the back of the mailpiece,
or on the front if space permits.
D. is delivery address different from Item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
(� 1
lei cc LA�e.
r2Article
I3. S rvice Type
&Certified Mail ❑Express Mail
egistered ❑Retum Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
Number = ?0 Os7 3 0 2 0 0'p b�1 n3 4t2 9}ansferfrom service laben
PS Form 3811,February 2004 i i i Domestic Return Receipt 102595-02-W540
I
UNITED STATES POSTAL SERVICE r •• r
R R iCt=-el m(, Z PTA, C12 � ..��',w�F �� WP
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° Sender. Please print your name, address,"and ZIP+4 in this box• AAA
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Town of*Barnstable
l"l s"JJ Health Division
200 Main Street
HyammisI MA 02601
i I
12.W4"fCit c-T
I _
WE Tp� 1 ..
Town of Barnstable Barnstable
o er i ce s De artmentRe ulatrS
UARNSTA6LE,
"A .
,639. Public Health Division . W
iOTeo MAY a 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644
c Thomas F.Geiler,Director
FAX: 508 790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 7007 3020 0001 3429 7649
_ January 7, 2009
Carole Darelius
11.Joyce Lane
Bellingham, MA 02019
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 12 Vermeer Court, Osterville, was inspected
on December 16, 2008 by Jaime Cabot R. S., Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of a rental inspection.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500- Owner's Responsibility to Maintain Structural Elements
Ten (10) windows in the dwelling do not function properly, tracks in window frames fall
off when malfunctioning windows are opened .
.105 CMR 410.300—Sanitary Drainage System Required
Septic system designed for three bedrooms. Finished unheated basement room can not be
used as a fourth-bedroom. Room in basement not to be used as a.bedroom.
105 CMR 410.5527 Screens for Doors
No screen provided for sliding door.
105 CMR 410.482- Smoke Detectors and Carbon Monoxide Alarms
No Carbon Monoxide Detector provided in basement finished room.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing a Carbon Monoxide Detector in the lower
level room and removing the bed from the basement finished room and to have in
place a screen in sliding door by April 1, 2009. You are directed to correct the
violation listed above within thirty (30) days by repairing the windows that do not
function properly:
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's.failure to
comply with an order shall constitute a separate violation:
Should you have anx questions regarding the above violations, please contact the Town .
Health Divi ion and ask to speak with.the inspector who performed the inspection.
(:�_A_
RDER OF THE ARD OF HEALTH Thomas A. McKean,R.S., CHO,
Director of Public Health
Town of Barnstable
i
� m
Message Page 1 of 1
Desmarais, Donald
From: Anderson, Robin
Sent: Monday, August 02, 2010 3:32 PM
To: mmacneely@commfiredistrict.co,m; Chief; Craig Tamash (tamashc@barnstablepolice.com);
dchase@hyannisfire.org; Deputy Chief Dean Melanson (dmelanson@hyannisfire.org); John Cosmo
Qcosmo@hyannisfire.org); Mike Grossman (mgrossman@commfiredistrict.com); Wadlington, Ellen;
Barrows, Debi; Crocker, Sharon; Desmarais, Donald; Lauzon, Jeffrey; McKean, Thomas; Mckechnie, .
Robert; Miorandi, Donna; O'Connell, Timothy; Perry,Tom; Roma, Paul; Stanton, David
Subject: August BIRST s
The following properties will be the subject-'of BIRST inspections Thursday,evening
(8/5/10):
o25 River Road, MM - reported that bays are being used for commercial use (residential
lot)
43 Elliott St, Centerville catering, work trucks, over crowding - reported that people
sleeping in shifts G9,11 1QA 4�16+'Ql�i 3 10' per '
—67 Huckleberry Lane, MtA basement apt girl rented unit - gave owner "a lot money" - '3
owner says apt not ready and won't return money.
--92 Head Waters, Centerville - former Amnesty unit - new owner - no permit to restore.
to sf ,-� s 1 Z1�-•��
—829 0sterville-W13 Rd, MM withdrawn from Amnesty but no permit to restore to sf 38a0,�
-e23 Tupelo Rd, MM - efficiency apartment Fisted for rent
All parties to meet in the rear parking lot of 200 Main Street for a 5 PM departure.
Robin C Anderson -
Zoning Enforcement Officer
Town of BarnstabCe
200 Main Street
Hyannis, -'AI t 026oi
5o8-862-4027
5o8-922-6432 ceCC
8/5/2010
McKean, Thomas
From: McKean, Thomas
Sent: Wednesday, March 2.2, 2006 8:24 AM
To: Taylor, Madeline
Subject: APPLICATION DENIED-829'Osterville West:Barnstable Road
The application regarding 829 Osterville-West Barnstable Road is denied. Only three (3) bedrooms maximum are allowed
there. The submitted application indicated four bedrooms are requested.
I reviewed both the Health Division and Building Division files and found the following:
- This site is located within a nitrogen sensitive area. The parcel is 0.46 acres in size. Therefore, the number of;
bedrooms is limited to one bedroom per every 10,000 square feet per Title 5, adopted March 31,-.1995.
In 1979, a three bedroom disposal works construction permit was issued by the Health Division.
- In 1992, a building permit sign-off was approved fora family apartment. However, the existing dwelling was to contain a
"bathroom" and a "common den area" at the second'floor according to the submitted floor plan, keeping the property
limited to three bedrooms. However, instead of a bathroom, the submitted sketch with the septic questionnaire shows a
"bedroom" in that same area.
Therefore, the request for four bedrooms is denied. t
0 Town of Barnstable Barnstable
WkmedaCft
Regulatory Services Department
s,�vs�rasz.e,
Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508 790 6304 Thomas A.McKean,CHO
11/09/09
William Anderson TRS.
23 Elliot St.
4
Centerville, MA 02632
Re: 43 Elliot St.
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at, 43 Elliott Street, Centerville,MA was last inspected.on
6/20/2008,by Robert Paolini, a certified septic inspector for the State of Massachusetts. -
The inspection of the septic system showed that the system `Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
"Sandy soil, signs of hydraulic failure, pit was full at time of inspection with stain
lines up in risers."
The deadline for repair ha We, The Department of the Board of Health have not
been informed that you have taken any steps to bring your failed system.into compliance.
Therefore, you-are ordered to repair or replace the septic system within 60 days from the
date you receive this notification.
You may request a hearing before the Board of Health, a written,petition requesting a
hearing on the matter, within seven (7) days after the day this order was received. '
Failure to repair/replace the septic system.within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOA , OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health ( O
c�
THE Town of Barnstable
P�Of Tp�y
Regulatory Services
BARN3TABLE, = Thomas F. Geiler, Director
MASS. Q
i639' a,, Public Health Division
ArFD MA'S
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
December 17, 2008
Attn: C.O.M.M. Fire
Health Inspector Jaime A. Cabot 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):
12 Vermeer Court, Osterville, Assessors Map-Parcel: (146/125/)
- Carbon monoxide detector not provided for Basement Play room
ime A. Cabot, Health Inspector
QAOrder letters\Housing violations\Rental ordinance\\Fire ViolationsTIRE TEMPLATE.doc
,t TOWN OF BARNSTABLE —
LOCATIGN Z (�Pf �' C�' SEWAGE # -;ifQe't10n
VILLAGE Q�'��Q(`tl`►�� ASSESSOR'S MAP & LOT c
l i&�S NAME&PHONE NO 41v611LIC
SEPTIC TANK CAPACITY LM
LEACHING FACII.TI'Y: (type) i�T (size)
NO.OF-BEDROOMS---
BUILDER OR atiMk yJ A fe.r—
PERMTTDATE: C DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
2 3l i
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FORM30 C_ HOBBs&WARREN M THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/TOW N
W H &ul�A
P DEPARTMENT
zoo 1 ►4 S(
ADDRE S `��� ` �� 7(o qq
p b S-T6e-V1 LL E TELEPHONE
Address f Z �� Sfi.4, 1 • _ Occupant_DIP� �- L/ 9AU S
Floor `Z Apartment No. No.of Occupants /V ng c,L
No. of Habitable Rooms (;;k No.Sleeping Rooms .3
No.dwelling or rooming units_ No.Storie - 2
Name and address of owner �-�
(,C_ L" • StLA_\e-y_0,k A QZ1 Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑/M ,/ Doors,Windows: �A_Q
Roof (,—i rj DOL,, NJ
Gutters, Drains: AAC� c (_LS. oel=
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation: V-0 Ur^ U S
Dampness: t3�.•(.,
Stairs: QC JE
Lighting:
STRUCTURE INT. Hall,Stairway: A10 &j tf, Z
Obst'n.: Lem-fcA_ L t;V 4z- Acpom
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows: A/0 Cgt c� 4, &i0"v off-
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring
WELLING UNIT
Ventil. to 0 is WI-Ifs Ceils. Wind. Doors Floors,,focks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3 S
Bedroom 4 S
Hot Water Facil. Sup.Ten.,G i, Elect..
Stacks, F es,Vents,Safeties:
Kitchen Facilities Sink `
Stov
Bathing,Toilet Facil. Vent., Iumb. S
Wash Basin, Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted a OS1
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES PERJURY."
INSPECTOR 4 TITLE X�_
64
DATE 2 Ale �> TIME z 911/kj
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger.or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105'CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
4 SMITH CIRCLE
LAKEVILLE MA 0234
'PH:5080475 1 86
FAX 5089469291 �
CELL5088 1 37467
I
; To BOARD OF HEALTH AGENT x
PER OUR PHONE CONVERSATION ON 3/I/07 ABOUT 1 2 VERMEER COURT OSTERVILLE MA WHERE 1 INQUIRED AS TO THE s
{
DESIGN CAPACITY OF THE SEPTIC SYSTEM AT THAT ADDRESS SINCE THERE WAS NO DESIGN PLAN ON FILE AT YOUR OFFICE.YOU I
a
I
STATED THAT IF THE 6FROUND X5' DEEP PIT HAD 2' OF STONE AROUND THEN THE DESIGN CAPACITY WOULD BE FOR 4 I
BEDROOMS ON 3/7/07 1 RETURNED TO THE PROPERTY AND EXCAVATED..DOWN TO BELOW THE TOP OF THE PIT AND
DISCOVERED 2' + OF PEA STONE AROUND SEE ATTACHED PHOTOS' I HAVE ALREADY FILED THE TITLE V INSPECTION AS A
THREE BEDROOM DESIGN AND WOULD LIKE TO AMEND THIS TO-4 BEDROOMS . PLEASE ADVISE THE PROCEDURE TO CORRECT +,
THIS .
THANK YOU
KENNETH ARPIN
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COMMONWEALTH OF mmsACHUSETT5
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r '
Y `
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ✓ �. ����
PART A
CERTIFICATION All
Property Address:i o7
Vz le ?WA—
Owner's Name:
Owner's Address: i/ o
Date of Inspection: oZ - /3 -o 7
Name of Inspector: lease print) ie h h �n
Company /`Pi n Cn r.io
P y Name: _.--r- PervGce, .
Mailing Address:
Telephone Number. Sr7 e 9 K7: $_ c �
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported `
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEf'2 . .�
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: L
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority-
Fails
Inspector's Signature: - _ Date: -l 3-o 7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DER)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority. V y S i e.rrl c'0,4 r 15—7 D F A /l)w 9/3-` o-1 7'fWe A &S -fi-/b cJ 7iV7 8,04
ANcf A L '2 )c 6 "b psT— S- 'Be%w dnler- Mc--me, �,p 3 BedraoP7,$'14AJIcjt f
Notes and Comments 6),q /n v A; la ,4 G? e4 vA e,,g-,v— 1q to ou. —
S mo 4-74 V.,, o Per,ed P�770A. DAB o4 .� Wei'ti
/-,� Ski'»l� �n /0C e>`ew tn le�� ..Z�idi IV 1zt� c� ���6 4 Ir �S,/"e
****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.
nape 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: � Dsie'-uoIe L1,4
Date of Inspeqction: _2 4 3—el 7
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
YC-s 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 Passes:
O 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.
LJO 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.
i
ND��explain:
AA
v'6)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:
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:
2 ,
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection: c` 13-c� 7
C. Further Evaluation is Required by the Board of Health:
N O Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
su-rface 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 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
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY
SSES
FORM SMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART A
CERTIFICATION(continued)
Property Address:
Owner: e
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
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed ppe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone of apublic well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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.]
No (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 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 amapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"`yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: / L
Owner: S
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
_ Were any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,�tKcluding the SAS, located on site'?
A _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
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
Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: l)
y
Owner: i"o r
Date of Inspection: o!—!3 -o
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design):3— Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ,S'3 cn
Number of current residents: 0 AJO
Does residence have a garbage grinder(yes or no):—
Is laundry on a separate sewage system(yes or no):N 0 [if yes separate inspection required]
Laundry system inspected(yes or no): Aj 0
Seasonal use:(yes or no): AJ-0
Water meter readings,if available(last 2 years usage(gpd)): ,
Sump pump(yes or no): /00
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgtetc.):
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: 2 VVeA ei 4-zA '.y
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach'previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date'installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): K.,�e
6
Page 7 of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:J,� Y Late er Cr
Owner:Cara 1. 64re,L i u r
Date of Inspection: -3 0 7
B 7ILDING SEWER(locate on site plan)
Depth below grade: c,
Materials of construction:_cast iron r<40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on//condition of joints,ve(n�tjng,evidence of le/a'kage,e�tjc.)�:
SEPTIC TANK:Yd(locate on site plan)
Depth below grade: /oZ" -
Material of construction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: DC �L
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: �3
Scum thickness: 0 �1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: /�y
How were dimensions determined: �'�S'u
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relatp4to outlet invert,evident f leakage,,etc.):
!'
GREASE TRAP: locate on site plan)
Depth below grade:—
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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:�A�.sL
Date of Inspection: j3"d 7
TANK:/�� tank must be pumped at time of ins ection)(locate on site plan)
TIGHT or HOLDING T ( p p P
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: ` S'(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: " O
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaka a into or out of box,etc.):
o
PUMP CHAMBER: (locate on site plan)
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.):
R ,
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C, Q
Owner:��1/,.rLj' r
Date of Inspection:
TIGHT or HOLDING TANK:/4J6(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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: la(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Q
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaka a into or out of box,etc.): L
o l Gc d d cJ c� 0
PUMP CHAMBER: (locate on site plan)
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.):'
R `
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: n e e
Owner: -j 6 D®r i""<
Date of Inspection: cP —73 -d 7
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Z
leaching pits,number._
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
P' olrl �^` S c�`i P,i i <,a4 s
CESSPOOLS:100(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: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil;signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 0
Lo
s-�
Owner: r `a—c,
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
Orvre"'9,y
GArA9e
�ecK
Yea sr4Pes
"Ta
gear
�D A c; -3
A 3 V
Tb
£ gTB � 3 �
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: la y6CM4P."- or-
6 c11/18 J4A
Owner: r!)(, QArP,(.i
Date of Inspection: o`Z - 13-07
SITE EXAM
slope y,4-p"j s!c Pes !D' Q-n 5�reez—
Surface water
Check cellar
Shallow wells
Estimated depth to ground water C�b feet
Please indicate(check)all methods used to determine the high groundwater elevation: .
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150, et of SAS)
Checked with local Board of Health-explain:Q 417Btn rd 1 114PS Ar 134 '
Checked with local excavators,installers-(attach documentation)
—&,Accessed USGS database-explain: NAPS' ATT 9Jh
You must describe how you established the high ground water elevation:
_ 11
4
}
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
e`
S�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM '
PART A
CERTIFICATION
Property Address: 12 Vermeer Court
Osterville MA 02655
Owner's Name: Norman Watier
Owner
's Address: Same n-
c
Date of Inspection: May 18,2005 Job#05-142 N)
Name of Inspector: PATRICK M.O'CONNELL =,
Company Name: SEPTIC INSPECTION SERVICES CO. _
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779 rn
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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;�0 F11ittp1
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: `�w N OF
_X_ Passes G
Conditionally Passes P RIC •,n::
Needs Further Evaluation by the Local Approving,Authority ; M
Fails
0
Inspector's Signature: Date: 5/18/05 ''�i,���lF5 $PQ�```
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments: Leaching pit has 12-18"-effective leaching.
****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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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 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.
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:
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:
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:
T:tla 9 Incnartinn V—411 VIM() 2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
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(I)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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:
Trtla C incnar inn V—411 C/7nnn 3
f
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
—X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X Any portion of a cesspool or privy is within a Zone I of a public well.
_ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
No_(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 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—I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Titles C 1ncn—f;nn V—A/1 G/�Ml1 4
I
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X _ 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?
_X _ 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
_X_ _ Existing information. For example,a plan at the Board of Health.
X _ 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(3)(b)]
Titles G inennrtinn Fnrm(.it�i�nnn 5
r '
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003—50,000 gal.2004—47,000 gal.=132 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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: Tank pumped 2-3 years ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_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):
Approximate age of all components,date installed(if known)and source of information:
1983
Were sewage odors detected when arriving at the site(yes or no): No
Titles C 1nonantinn Rn—A/1 VIMA 6
Ill _
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005 ,
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_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: XX (locate on site plan)
Depth below grade: 1'
Material of construction:_X_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5' long x 5.2' wide—1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness: trace
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Baffles intact and clear, liquid level at bottom of outlet Dive.
GREASE TRAP: No (locate on site plan)
Depth below grade:_
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.):.
Titles C Inenartinn Rnrm r,11 C/7nlnn 7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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: XX (if present must be opened) (locate on site plan)
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.):
No solids or high stains.
PUMP CHAMBER: No (locate on site plan)
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.):
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005,
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
—X_leaching pits,number: One 6x6 pit.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, '
etc.): Liquid level in pit is 18" below inlet pipe with a high stain line 6"above current level.
CESSPOOLS: No (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:
r
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
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Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
Vermeer Court
Driveway
#12
Garage
36
31 31
26
46
34
I
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Vermeer Court,Osterville
Owner: Norman Watier
Date of Inspection: May 18,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 15 feet
Please indicate(check)all methods used to determine the high ground water elevation:
i
Obtained from system design plans on record- If checked,date of design plan reviewed:
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el. 15 and topo map shows property above el.30.
x
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