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0113 WEST BAY ROAD - Health
f 113 West Bay Road, Osterville - LA=-- 116-032 p r • x I I I 6?10 No. Fee 7S THE COMMONWEALTH OF MASSACHUSETTS Entered in co uter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYieation for Misposar 6pstem Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ( (3 WE sr OA-Y 4 Owner's Name,Address,and Tel.No. rCRVCAssessor's Map/Parcel ® ®� d 'I bew4� � ��� PW Installer's Name,Address,and Tel.No. 'j p S-C1 Z7-S'8 7 7 Designer's Name,Address,and Tel.No. F t ©UP, C.U. v-1, MIA Type of Building: I Dwelling No.of Bedrooms N I Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) I�' gpd Design flow provided /V//�' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) :T jj� &,( �� ) (-{-(Q D-V_Q)p Lxj IT�La ''EP, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b is Boar of He h. S Date a Application Approved by Ial4WDate IM D Application Disapproved by a Date for the following reasons Permit No. Date Issued kS'.1'fiY-.r' 7b*.dgr,l�'Y,"R'P,�''4 Y'•yy-f,Yr vq., 'rR:.'.•S.M.:"i:.•u•i ..,..r r< ..j.._�.^+�+m, 1bT.,.w+ P .y,,.eF-:..,�d dFti1+eF'/ S liP h1S ..rr :�e .,, .iY_ c y, M No. Fee 1/ -x � THE COMMONWEALTH OF MASSACHUSETTS Entered in com. uter: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0"plication for disposal Opstem Construction Permit Application for a Permit to Construct( ) Repair(%A Upgrade( ) Abandon( ) ❑Complete System Individual Components r` s Location Address or Lot No. + ( (ASS r O.V PJ> Owner's Name,Address,and Tel.No. ®Sr "�OR$cAls6 V (t1�1� Assessor's Map/Parcel, b(g Zo 3 Installer's Name,Address,and Tel.No. 50S�-q77.gS7 7 Designer's Name,Address,and Tel.No. R i 6 ook do. C r Ul u-14i Type of Building: Dwelling No.of Bedrooms �'r Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) r% gpd Design flow provided N I/� gpd Plan Date Number of sheets Revision Date , Title Size of Septic Tank Type of S.A.S. Description of Soil v> t Nature of Repairs or Alterations(Answer when applicable) ="C"P*,/� „jt- ) 1-4-1 O D-J1 ' (Al jte4 RISE� Date last inspected: ». 4 . Agreement: ^~- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has„been issued b is Board of Health. CX,AxC Date S"Ix—U a� Application Approved by Date32 Application Disapproved by Date for the following reasons Permit No. ''' Date Issued - - -=------- ------------------------------ ---_-- --- ------ _ _ - _ - - - -..•, .._.... Y THE COMMONWEALTH OF MASSACHUSETTS 6 /� BARNSTABLE,MASSACHUSETTS 6X Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� ) Upgraded( ) Abandoned( )by R*adz_a a?Q[_ , 1 dSTZaS!! has been cons "'ndce with the provisions of Title 5 and the for Disposal System Construction Permit N . d ed 9 4.1 ,2 ra Installer ADAOiM G 60k 00. Designer #bedrooms �/�/ Approved design flow gpd The issuance of is pe it shall not be construed as a guarantee that the system wil functi design „ t Date 3( � A Inspector 1 t No. Z R_BUD Fee THE COMMONWEALTH OF MASSACHUSETTS;_.,., PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) ' System located at 113 WE$'T 8&f ROAD b$'j'&j3,Y/L 4,�5 t and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construct t be c�o ted nthree years of the date of this permit. Date Approved by i Town of Barnstable BAWNSIABLE, + - ,A 039, Inspectional Services Department Public Health Division 200 Main Street, Hyannis MA 02601 se, Office: 508-862-4644 �"* FAX: 508-790-6304 "� Thomas A.McKean,CHO r d , 08 c�,,��f�� J�'J, Feb 6, 2007 II Rev. 4/26/19 l /tPDEADLINES TO REPAIR FAILED SYSTEMS 6�1)1� (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe" ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis,: (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA o Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ' ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20. h) OTHER 1 Repair deadline: Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc I � Commonwealth of Massachusetts (� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 113 West Bay Road F b Property Address Terry Dimek_ c Owner t. :• Owner's Name information is Osterville ✓ _ MA 02655 _3-10-20 required for every page. City/Town State Zip Code Date of Inspection 6 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: II LL N OF tM uii���� Important:outfWhen �� (T�33 ���_�. • ...... 9C,y fillingout forms A. Insp ector Information • G% on the computer, ;gam' JAMES (P use only the tab James D.Sears_ _ e M: : key to move your Name of Inspector :rn cursor-do not Robert B.Our Co INC � use the return ------- -- — ��J-'•-F;e�-�.=o�--�•a key. Company Name �i,���� ... . ..• G��`��. 363 Whites Path p�i71,u H11,N SPt00��` ICI Company Address — South Yarmouth _ — MA_ _02664 City/Town State Zip Code 508-477-8877. _ _S1623 Telephone Number , License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my 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 „ ft t � ._�a�_ _aho --._ 3-10-20 _ I ector'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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts Title 5,Official Inspection Form F Subsurface Sewage Disposal System Form Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 3-10-20 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: Conn Pass- D Box. The system is a 1000 GaLTank D Box and pit. 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): 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 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is required for every Osterville MA 02655 3-10-20 page. CityrTown 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): _ Need to replace D Box. ❑ 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cry Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 3-10_-20 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 El ® 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 3-10-20 required for every _ — 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 awapW is less than 6" below invert or available volume is less than Y2 day flow Pi7— ❑ ® 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 10000 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 3-10-20 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section 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 ❑ ® 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 El ® this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were'all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® information on the proper'maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 3-10-20 required for every —. page. City/Town State Zip Code Date of Inspection D. System Information I. 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 Description: 1000 Gal. Tank D Box and pit. 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ 'Yes ® No Water meter readings, if available last 2 ears usage 2018-14,000GaIs g ( y g (gpd))'Detail: 2019-13,000Gars � — + w Sump pump? El Yes ® No Last date of occupancy: NA Date t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !% 113 West Bay Road Property Address Terry Dimek 'Owner Owner's Name information is required for every Osterville MA 02655 3-10-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) .4 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: NA 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 Title 5 Official Inspection Form '- .' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 West Bay Road V Property Address Terry Dimek Owner Owner's Name information is Osterville required for every MA 02655 3-10-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1988 Permit # 88-401. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: ' 2811 feet Material of construction: ❑ cast iron Z 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pi ein is 4" PVC SCH -40. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 I c Commonwealth of Massachusetts �� g� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .;, 113 West Bay Road L- Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 3-10-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ® concrete ❑ metal El 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 1000 Gal. Precast H-10 Dimensions: 211 Sludge depth: - Distance from top of sludge to bottom of outlet tee or baffle 2811 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape 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.): Tank at working level. Tank and covers at 18" below grade. In and outlet baffle. No sign of leakage or over loading. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I Commonwealth of Massachusetts �n .. ,T Title 5 Official Inspection Form '�_ l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek _ Owner Owner's Name information is required for every Osterville _ MA 02655 3-10-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yv`�( 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA 02655 _3-10-20 required for every 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-2' Below grade w/one line out. Wall's are gone on box. Need to replace D Box. 151nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts iP Title 5 Official Inspection Form 'F �i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is psterville _ MA 02655 3-10-20 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.): *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: _ 1 ® 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: — t5insp.doc•rev,7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 r Commonwealth of Massachusetts ' Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is Osterville MA •02655 3.10-20 required for every 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.): - ' Leaching is a 1000 Gal. precast pit. Pit and cover at 17" below grade. Pit is dry w/clean wall's. 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.): t5insp.doc•rev.7/26/2018 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J� 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is required for every Osterville MA 02655 3-10-20 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.): A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 ,. Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is required for every Osteryille MA 02655 3-10-20 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 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vL 113 West Bay Road Property Address Terry Dimek Owner Owner's Name information is required for every Osterville MA 02655 3-10-20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N® Estimated depth tough ground water: 3 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: Past Report&GIS. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W.30'. Bottom of pit at T6" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form -1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 West Bay Road Property Address Terry Dimek _ Owner Owner's Name information is required for every Osterville MA 02655 3-10-20 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 r o7toM- 3© t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DispoI System Form -Not for Voluntary Assessments Roper TAddress Oro ner Ory ner's taame -- inforrration is required for every page. City/Town D. System Information (cont.) Zip Code oats of Inspection Sketch Of Sewage Disposal System: PrwAde 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; )k hand-sketch in the area below El drawing attached separately � t (D 01iL_ rl JJ BF 1,4 /I 1�2 e 7 Sn5.3113 Tite5Official Impaction Form Subsurf ace SeregeDisposal System-Page 15of 17 i 1 e Commonwealth of Massachusetts Title 5 Official Insp ect ®n Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address - Owner s Name information is. / 4? required for ��'�"°C��(/� I/ V—te �A60every page. City/TownDate of Inspection. Q! M 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 A. General Information - out forms on the computer, use only the 1. Inspector:tab move to moour cursor-do not Name of Inspector use the return key. Company Name r 1�t Company Address Ctty/Town State lCo �o ac36e: Z Zip Code +� Telephone Number License Number B. Certification „ I certify that I have personally inspected the sewage disposal system at this address and that the t information reported below is#rue„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: T [ Passes ❑ `Conditionally Passes ❑ Fails /❑ Needs Further Evaluation/ he Local Approving Authority Inspector's Si§Ratlfe Date i The system inspector shall submii a copy of thi's 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. ****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. 15irts-3>13 Title 5 official Inspection Form:Subsurface.Sewage Disposal System-Page 1 of 17 - d d V f Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address. Ow ner Ov ner's Narne information is _ required for every "G/7✓GIB-!/UGC , " (� j� 5 /6 page. CitylTown State Zip Code Date of Inspection B. Certification (cons.) Inspection Summary: Check A,B,C,D or E/alwayscomplete all'of Section D A) System Passes: 1 have not found any information which indicates that any of the failure.criteria described,.' in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments:. 1 B) System Conditionally Passes: ❑ On r more system components as described in the"Conditional Pass'section need to be replac or repaired. The system, upon completion of the replacement or repair, as approved by the Boar f Health, will pass. Check the box for"y " "no"or"not.determined"(Y, N, ND) for the following statements. If"not.' determined,"please'ex in: k The septic tank is metal and r 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial in ation or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repi ed with a complying.septic tank as approved`by the Board of Health. *A metal septic tank will pass inspection if it i structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than years old is available. ❑�Y ❑ N ❑' ND(Explain below): t5n5.3M 3 Title 5 Official Insp ection Form Subssrface Sevoge Disposal System-Page 2of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PropertyAddrss�s� Owner Ow ner's Name isinformation , / required for every � �U l C C ;. �✓� 2�/,9 Y page. Cityrrown State Zip Code Date of inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if punii ips/alarms are repaired. B) System onditionally Passes(cont.): Observation o wage backup or break out or high static water level in the distribution box due' + to broken or obst ted pipe(s)'or due to a broken, settled or uneven distribution box. System will pass inspection if( approval of Board of Health): - ❑ broken pipe(s)a replaced` ❑ Y ❑ 'N ❑ ND(Explain below): ❑ obstruction is remov ❑ Y ❑* N ❑ ND(Explain below): ❑ distribution box is leveled o replaced ❑ Y ❑ N ❑ ND(Explain below). ❑ The system r cared, Y eq 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 8�,Health): ❑ broken pipe(s)are.replaced ❑ Y ❑ N . ❑ ND(Explain below): El obstruction is removed El Y. 1-1N< ❑ (Explain below): 4 C) Furthe aluation is Required by the Board of Health: ❑ Conditions exis ich require further evaluation by,the Board of Health in order to determine if the system is failing tect public health, safety or the environment. 1.7 System will pass unless rd of Health determines in accordance with 310 CMR 6.303(l)(b)that the system is no nctioning in a mannerwhich will protect public health, safety and the environment: Cesspool.or privy is within 50 feet of a surfacewater 4 ❑ Cesspool or privy is within 50 feet of a bordering veget ed �tland or a salt marsh 65ns•3n3 Tide 5Moist Irepwbti iFom SubsWace Se%%eDisposal System•Page 3ot17 .. f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments RopertyAddress - 12 Ow ner Ow ner's Narr>e� information is required orevery ✓�� � ���,� �2��-1� page. City/Town State Zip Code Date of Inspection B. Certification (cont.) / 2. S will fail unless the Board of Health (and Public Water Supplier,If an , P any). determine that the system is functioning in a manner that protects the public health, safety and a vironment: ❑ The system h a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface ter supply or tributary to a surface water supply. ❑ The system has a s tic tank and SAS and the SAS is within a Zone 1 of a public water supply ❑ The system has a septic nk'and SAS and the SAS is within.50 feet of a private water supply well: , ❑ The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply II**. Method used to determine distance_ **This system passes if the well water analysis, rformed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence •f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure cn ria are triggered. A copy ofthe.analysis must be attached to this form. 3. Other. D) System Failure'criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of thefollowing 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 pf�- Liquid depth in cesspool is less than 6"below invert or available volume is less 'than day flow . t5uu•3M 3 'rite 6.Official impection Form Subsuface Savage Disposal system•Page 4of 17 Commonwealth of Massachusetts _ + Title 5 Official lnspdcti®r ' F rrr Subsurface Sewage osal S smem Form=Not for,Voluntary Assessments ' RopertyAddress. Cw ner ON ner s Na information is % \ a required for every 1� ®. �- ��� _. • .-Z,S �� Page. CRY/Tow n State Zip Code Date of Inspection G B. Certification.(corn) Yes x. No' r ❑I, kRequired.pumping more than 4 times in the.last yearNOTdue to clogged or obstructed s Ndmberof.times pumped:' P Pei )• s ❑ a V : Any portion of the SAS,'cessp6oi or privy is below.high-ground waterrelevation. Any portion of cesspool or privy is within 100+:feet of a surface v+rater supply or, tributary to a-surface water supply N ` -.' t �x . ❑ �� �l Any portion of a cesspool or privy is within a Zone 1°of a public well..r ❑ �� Any portion of a cesspool or privy is,within 50feet.of a private water;supply well Any,portion of a cesspool or privy is less than 100 feet but greater than 50Yeet `from a private water supply well with no acceptable water quality analyses ;[This system'passes if the well wateranalysis, performed at a DEP-certified - laboratory, for fecal.coliform bacteria indicates absent and the presence f« of ammonia nitrogen and nitrate nitrogen is equaFto 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 vrith a design flow of 2000gpd 10,000g pd. The system fails. I have determined that one or more of the above failure ".` r ` criteria exist as described i n 310 CM R.15.303 therefore the system fails. The . r system owner'should contact the Board of Health to determine what,will be : necessary",..to correct the failure: E) Larg ystems: To be considered.a large system.the system must serve a facility witha . design Of 000;gpd to'15,000 gpd. UV e.. a For large system ou must indicate either"yes"or"ho.to each of the following, in addition to the questions in Section Yes No µ ❑ ❑ the system'Is vui in 400 feet of a surface drinking water supply the system is�nnthin 200 of a tributary to a surface dnntung water supply❑ the system is located in a', itroge ensitive area(Interim Wellhead°Protection ' Area= IWPA)or a,mapped Zone`II public water supply well ffyou have answered"yes°,to`any question in Section E the'syste is considered a',significant threat 'or answered "yes"in'Section D,above the large system has failed. caner or operator of arty large system considered a significant threat under Section E or failed under Sec i -D shall upgrade the 4'system in accordance with 310 CMR 15304.'The system owner should contact t�ppropriate' 3 regional office of the Department. F' 15ns•3113 Title 5 Offiaal Inspection Form, Subsurface Sewage Disposal System-Page 5 of 17 A.. . Commonwealth of Massachusetts Title 5 Official. Inspection ®r I= m Subufrtace.Sewage Disposal System Form -Not for Voluntary Assessments 43 ��� � A� Pfoperty Address Owner Owner's Na requiretio is required for every page. CityfTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate`y+es"or"no"as}to each,of the following: Yes No tp ❑ 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? ❑ I� 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, exelad M 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: x ❑ , Existing information. For example, a plan at the Board of Health.011 fr le jfEl 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms*(actual): —`— ---- DESIGN:flow based on 310 CMR 15.203(for example:•110 gpdryx#of bedrooms): LSns•3H 3 Title 5 Official Inspection Form:SubsW ace Sewage Disposal System•Page 6 of 17 .` • .. Commonwealth of MassachusetlWs Title 5 Official Inspection ,Form* Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ` ON ner ON ner's i b inforrtion is required for every rra "—' "d /� f��GJ.7� 4b—116 page- City/Town Stafe- Zip Code Date of hspection D. System Information Description: r. Z. Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection information in this report-) ❑ Yesy� No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes I No Water meter readings, if available(last 2 yearn usage(gpd)): Detail: Sump pump? El .Yes, No Last date of occupancy: l� Date A//4 Comm cial/1 dustrial.Flow Conditions: Type of Establishm Design flow(based on 310 CM .203): Galrons per day(9Pd) Basis of design flow(seats/persons/sq.ft-, tc:): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank,present? ❑ Yes ❑ No ., Non-sanitary waste discharged to the Title 5 system?- ❑ Yes ❑ No Water meter readings; if available'- 9ns•W 3 Title 5 Official kspecdon Form SLbsLiface Sevage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form m Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments Wo Property Address , Oyu ner Owner's Name inforrnation is required for every v�'�'-�w`LC` 4�Z6�5 B—Z,S page. Ckyrrown State Zip Code Date of Inspection D. System Information .(coat.) l/V Last date of occupancy/use: Date Other(descri low): General Information Pumping Records: Source of information: - g Was system pumped as part of the inspection?. (� -y/es No If yes, volume pumped: - `G✓ d' G dwW �Ud r'Gl/llces56� gallons , How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑ W Shared system (yes or no) (if yes,attach previous inspection records, if any) a Y El Innovative/Altemative: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 !IA system by system operator under contract ' ❑ Tight tank. Attach a copy of the DEP approval. [] - Other(descri be): . V 45ns•3I13 TitleMfidal trspectionForm Subswlace SewQeDisposel System.page8of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Di osal System Form Not for Voluntary Assessments r RopertyAddress Ow ner Owners Name information is required for every page. Gtyrrown SiZte Z' Code Date of Inspection� , D. System Information (cord.) Approximate age of all components, date installed(if known)and source`of information: ` Were sewage odors detected when arriving at the sites {] Yes No Building Sewer(locate on site plan)` Depth below grade: feet Material of construction: cast iron ,40 PVC! .❑ other(explain): Distance from private water supply well or suction line: �feat ` 1� Comments n conditio of"oint , ving, vidence of leakage, atc. : Septic Tank(locate on site plan): Depth below grade: ' feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) h If tank is metal, list age' �. years rIs age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: ���� Sludge depth: t 15iris•3/13 • Tft50ffiaal IrspectionForm Subsurface SevageDisposal System-Page 9of17, r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow nw Ow ner's N meinforrngion is requited for every page- Wrown S Zi Code Date of hspeotion ®. System Information (cont.) - Septic Tank(coat.) ' Distance from top>of sludge to bottom of outlet tee r ffl Scum thickness - Distance from top of scum to top of outlet tee b e , Distance from bottom of scum to bottom of outlet tee ffle* - `4 Flow were dimensions determined? mtPu ping re om d�� ommerttsre om at inle n Doti tee o�conditio stnic ral integrity liquid s as related,to outlet inve enc�of leakage, tc.): .. 2 % O ,s► u� �g Grease Trap(i ate on site plan) 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 '3f13 Title50rfidd biepwbon Fam SubSW8M Sewage DJepoeal Syaiem-Page 16 d n, Commonwealth of Massachusetts' Title 5 Official Inspection Foy Subsurface Sewage Disposal Syslern Form-Not for Voluntary Assessments , lz3 - Property Address Qv ner aY ner's Narr3e inforUBtiDn iS requiredfor every o"'n Staff Zip Code [ete of tnspecbw D. System Information (corn.) - ,lf Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e4dence of leakage, etc.): fi Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below gibde. Material of construction. ❑ concrete ❑ metal. ❑ fiberglass ❑ polyethylene ❑ other(explain): y Dimensions: Capacity. aibns Design Flow. . g8b! r day Alarm present; ] Yes ❑ �Io Alarm level: Alarmtn worts rder: . ❑ yes No Date of last pumping: Date Cccunrrtents,(condition of alarm and float switches, etc.): Attach copy of current pumping cwtract{required). Is copy ® Yes C!.>No 3�3 Time50ffidd hwPwftnFoM Ua faw'%VMGDiposd S)SUM-Fa go 11 of 17 '.,l` - Commonwealth of MassachusetEs Title 5 ® icial Inspection Fo Subsurface Sewage Disposal SyMem FDrm-Not for Voluntary Assessments R'o "Address iraformatiM isowner's req*ed for every r+harre(2 !�.d re• CWTown state zip Code [ate of inspection D. System Information (cunt.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid le bove fn y, errts(note if box is r cusiribut' n t�t. equal evide ce f solids carry over Y rrry arty evidence of leakage into of out of box, etc.): y i y Pump Chain r{locate on site plan): r Pumps in working es El yes 0 No' r Alarms in working order ® yes 0 Comments (note condition of pump ber, condition of pumps and appurtenances, etc.): •'if pumps or alarms are not in working ordK' system is a conditional pass. Soil rption System (SAS)(locate on site plan, excavation rat required): SAS. located, explain _ y' 3H5 TM601kW kvpwkn Form SutesWwe SOVRRODia OW SYMM FVO 12 of 17 T Commonwealth of Massachusets . Title 5 Official inspection Fon Subsurface Sewage Disposal Sysiem Form •Not for Voluntary Assessments Property Address Cw tier ON MIS lvar-M inforrretion is regifired for every Pap- Cit sown state Zip Code Date of Inspeedon D. System Information (cone) n Type:, = { �. leaching pits number: ❑ leaching chambers 6 number. ,. ❑> leaching galleries number. ❑ leaching trenches J number,'iength; ' ❑ leaching'fields number, cimensions: ©` overflow cesspool number. ❑ innovativelaltemative system- L elname of technology: Comments(ndte conditio�n/o f soil, ydraullc failur , level of din soil vegdatio , ): �°y- 1. ! 9, p rt�on o YdCP a r 2 © O,��Cesspools(cesspool mustbe'pumped as part of inspection)(locate`on site plan)- Dun bar,aid co ion Depth top of Liquid to inlet in Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of constnrction t Inclicalion of grower invow, No [� 59ns•3'i3 k;a, 710e50Mc l ispwftn Farm system•page 13 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments RopertyAddress ///���/�(//��J Ow ner ON ner's Name information is required for every � //ILCC �'"�; � • � ' page- City[Town State Zip Code Date of Inspection, D. System Information (cots.) ' Commen (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t A11,4 Privy(I ate on site plan): Materials of co st o cti n: Dimensions Depth of solids • - Comments (note condition of soil, signs of by is failure, level of ponding, condition of vegetation, etc.): tSris•3/13 o Me5Offidd InspectimForrn Subsurface Sevoge Disposal System•Page 14 d 17 - Commonwealth of Massachusetts Title 5 Official inspecti®n',form Subsurface Sewage Dis�po I System Form:-Not for Voluntary Assessments Property Address �L®d OH ner ON ner's Name information is required for every page. City/Town State Zip Code Date of Inspection. D. System Information (cord.) 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, Wt ifs t5ns•3/13 Ti9e 5 0ffid;ks pecSon Fora[SLbsWace Se%%%e Disposal System•Page 15 d 17 i r Commonwealth of Massachusetts Title. 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Property Address Ow ner Cw ner's Name - information is required for everyy<L""� e/,1L_ 4i '7i� 1� page. Gty/Town State Zip Code "_Date of Inspection D. System Information (cunt.) L Site Exam: Check Slope d� r 1�9 Surface water. :OV � 7 Check cellar: ,,/A � Shallow wells �Estimated depth to high ground water.` � feet . Please indicate all methods used to determine the hi h/round water elevat i ) 9 9 on. ❑ 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 Iocal:Board of Health-explain: 0 Checked with local excavators, installers-(attach documentation)- ' Acces5od USGS database-explain. a������ You must describe how you established the high groundwater elevation: ®1 _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. ffins-y19 Title50ffiaal Inspection Fora Subsurface Sewage Disposal System-Page 16 of 17 F f. • , Commonwealth of Massachusetts Title 5 Official Inspectionform- Subsurface Sewage /Disposal System Form -Not for Voluntary Assessments • FToperty Address Orr ner ON ner s Name )information is required for every41 page- Cdyrrown State Zip Code Date of Inspection E. Report.Completeness Checklist Inspection Summary:A, B, C, D, or.E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed }$1 System Information—Estimated depth to high groundwater Sketch eof Sewage Disposal System either drawn on page 15 or attached in separate file ± y i t5�-3H3 TitleWkdd AupectionFam[Subsuface S9*6.goMoose!System-Page 17 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / � 9 a 3� Property Address .�v ECrJa�✓�.4�l�c ��fT � �2w�,�y /�. �v066�7�vTr>r E Owner Owner's Name information is ry �g��i��/,�LLLc /G` l/Llo �oP BS�� /dJ t,70�/� required for eve 2 7— page. Cityrrown 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. General Information �1 n on the computer, J1 yl Q� lV' use only the tab 1. Inspector U key to move your cursor-do not e���� � use the return key. Name of Inspector. Y Company Name P�9 Sax 17Z� Company Address �59�/Jw�c-lf %� DZ s^G3 City/Town State Zip Code Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on.site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: _ S2 C:) Passes ❑ Conditional) Passes s:: Y ❑ Fails, �:... ❑ Needs Further Evaluation by the Local Approving Authority Q` t Inspector's Signature Date f a s 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. ****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 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 � 13 �� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owners Name information isi/ � required for every page. Citylrown tate Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: [ 1 have not found any information which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: r B) System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be r laced or repaired.The system,upon completion of the replacement or repair,as approved by the and of Health,will pass. Check the bo r"yes","no or"not determined"(Y,N, ND)for the following statements. If"not determined,"plea explain. The septic tank is meta nd over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substan I infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank' replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectio ' it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less n 20 years old is available. ❑ Y ❑ N ❑ ND(Explain belo Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address G�.y�Zpo�Y Owner Owner's Name information for is 'Sr 27-14 required for every page. Cityrrown I o Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ servation of sewage backup or break out or high static water level in the distribution box due to ken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass I pection if(with approval of Board of Health): ❑ br en pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruc is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box' leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times ear due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the rd of Health): ❑ broken pipe(s)are replaced ❑ Y N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ ❑ ND(Explain below): A,/ C) urther Evaluation is Required by the Board of Health: ❑ Con exist which require further evaluation by the Board of Health in order to determine if the system is al' o protect public health, safety or the environment. 1. System will pass unle rd of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface r ❑ Cesspool or privy is within 50 feet of a bordering vegetate tland or a salt marsh Title 5 Official Inspection Form Subsurface Sewage ' sal System•Page 3 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Gr/�Ec�oy Owner Owner's Name information is Z257-,---W111zZC UZG S-'V- required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determ! that the system is functioning in a manner that protects the public health, safety and vironment: ❑ The sNceib a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a ser supply or tributary to a surface water supply. ❑ The sa ptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The s a septi nk and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system h tank and SA nd the SAS is less than 100 feet but 50 feet or more from a pr supply well".Method used te distance: **This system passes if the well water analysis, perf ed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criten are triggered.A copy of the analysis.must be attached to this form. 3. Other: 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 El 94 Liquid depth in cesspool is less than 6°below invert or available volume is less than Y2 day flow Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Property Address Owner Owner's Name information is z45A7,ul `� d 2G SS- fi'- 2 /¢ required for every page. _ Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ [] Any portion of the SAS,cesspool or privy is below high ground water elevation. 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 well. I ❑ 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.] ❑ N�� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) La a Systems: To be considered a large system the system must serve a facility with a desig ow of 10,000 gpd to 15,000 gpd. For large system , u must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fe a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributa a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area erim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water su well If you have answered"yes"to any question in Section E the system is considered a s ificant threat, or answered"yes"in Section D above the large system has failed.The owner or operator ny large system considered a significant threat under Section E or failed under Section D shall upgrade e system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is s 4 required for every �`��""" �4 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No �9 ❑ 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? ❑ j 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) J ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? 4rlc��y t ❑ Were all system components,excli�i�g�e 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 oil Absorption System(SAS)on the site has been determined based on: ft, r�T�l'i7�,�dn cQ 6P-it- 'as 4��8 ❑ Existing.information.For example,a plan at the I3gg oVGr altt�,,,, ❑ 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)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 .33 v DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Title 5 Official Inspection Forth:Subsurface Sewage Disposal Syslem-Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1/,3 ti/Fsr B•4 yua Property Address kt4 _W'0 ✓ Owner Owner's Name information is required for every State Zip Code Date of Inspection page Cityrrown D. System Information Description: cl-�Jajr row-3J L, P r- Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[f yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ❑ No A�4 Seasonal use? ❑ Yes (gf No Water meter readings,if available(last 2 years usage(gpd)): Detail: �(� 1l�GYj Zai3 !92 OGYJ ��30-3 o46 = 7-44) �2y Sump pump? ❑ Yes IV No Zp i? Last date of occupancy: bate I//�Co erciaUlndustrial Flow Conditions: / Type of Es 'shment: Design flow(based o 10 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsats/persons7s etc.): Grease trap present? ElYes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings,if available: Title 5 OlricW Inspection Fow.Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Gl/l�z��u Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Al�,� La7(descdnbe pancy/use: Date Obelow): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: N gallons . How was quantity pumped determined? M/4- ryO�/ rh�-e&--'W4f4Y Reason for pumping: Type of System: 19 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): Title 5 Offioal kq)ecbon Form:Subsudace Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments n A Q Property Address Owner Owners Name information is Ar72!/�CC� required for every State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): i Depth below grade: feet Material of construction: ❑cast iron P§40 PVC ❑other(explain): Distance from private water supply well or suction line: feet /l J-1(49 r-"/kz'4J"A�e Comments(on cond'ion of joints,venting,evid Pce of leakage,etc.): Septic Tank(locate on site plan): ZO�� Depth below grade: Material of construction: concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) 412 If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No A11A � 1�MII Dimensions:(���0`�� �xs-/ ��/ Sludge depth: Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address '�/`fezAl Owner Owner's Name information is �71 0-14 .-S rp 9eired for every Ciiy/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee r baffle Scum thickness .-qo Distance from top of scum to top of outlet tee baffle Distance from bottom of scum to bottom of outlet tee r baffle �! How were di n ions d�eetermined?g�odY°� 3' d qp ��iI/Qcpssar dUc� �. and o test tee or baffle conditioZstructifinte ty) mments r n pumping recomm do , I�t yti 9 iqui ,Iev�Is s related too et invert, Bence of leakage, etc.): GG - l���� yeris 5 av� /9`l/Ji.¢ 011 Grease Trap(locate on site plan): Depth b rade: feet Material of construc i ❑concrete ❑meta ❑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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner owner's Name information is OsT�n v,mow- required for every page. CdYffn State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid lev related to outlet invert,evidence of leakage,etc.): X/4 Tig t or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth be w grade: Material of cons ction: ❑concrete eta[ ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm level: Alarm i 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 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts 'UIW- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address / y Owner Owner's Name information is B 1 required for every �l l GE s 7 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outleet•n ert� mments(note if box is level and distribution to outlevega ny(vii?=f solids caryove)any evidence of leakage into or out of box,etc. . l}cr�t/ o6Z1 ump Chamber(locate on site plan): Pumps I rking order. El Yes ❑ No Alarms in working o r. ElYes ❑ No Comments(note condition of pu B c amber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): AS,*located, explain y: reel'-/ v r l •p Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments //� G�ESTB�Si,�>✓J Property Address Owner Owner's Name information is required for every page. Cifyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system T pe/name of IoCT Comments(no a conditi, n of soil, igof. ydraulic failure level of ponding, amp_sotIndition of /�h vegetation, ld W7 zj r '%4 C spools(cesspool must be pumped as part of inspection)(locate on site plan): Number d configuration Depth—top of liqu o inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 Property Address �h�LDoN Owner Owner's Name information isZ�— required for every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Priam cate on site plan): Materials of const Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failur , el of ponding,condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Serfage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �?/L�EZ Duy Owner Owners Name iequiredifore required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below. hand-sketch in the area below hv�cP I drawing attached separately 1I �l A- -2 IPA`-al e-2 2� '-©►, 92�7„ $-3 I Il I1 I S,4 D Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address l�Y�f ELDD� Owner Owner's Name information is O,ST�,�(/lGLE -St required for every — — page Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: D/ Check Slope ! (� [� Surface water � 'P?Lp Qr Check cellar zw-� Shallow wells 7G1i A/A)Arqj, 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: el-S a C sffs �1 4�lr 3.3 You must describe how you established the high ground water elevation: 2 Z4 Before filing this Inspection Report,please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 16 of 17 Commonwealth of Massachusetts tipTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is e- Z?-14 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist inspection Summary:A, B, C, D,or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed , ] System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Titte 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 3/4/2020 ShowAsbui It(1700x 2800) TOWN OF BARNSTABLE LOCATION_113 WEST 3AfY Ra SEWAGE i e ^ d VILLAGR D Sl-" ASSESSORS MAP A LOT /I:-O?a INSTALLER'S,NAME&PHONE NO.. A&B CANyO 775-626d SEPTIC TANK CAPACITY /000 4RL S%' ���w•k LEACHING FACILITY:(tgpe) P/T (size) /000�/L NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDBR OR DATE PERMIT ISSUED: 7 DATE COMPLIANCE ISSUED, 4� VARIANCE GRANTBD: Yes .-No J 99 � 3} II y9 0 i https:Hitsq Idb.town.barnstable.ma.us:8431/H ome/ShowAs,built?mp=116032&sq=1 1/1 TOWN OF BARNSTABLE ~ LOCATION 113 w F-s7" 'B l t4-' it SEWAGE# ,'e^ VILLAGE ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) i 7 (size) / o o 0 �AL NO:OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR DATE PERMIT ISSUED: +-^ ty DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r ` �. �e �,; � � '' �'; � _ o `�.a �� y �o w o �► ��.,. Bard of Health Town of Barnstable P.O. Box 534 Hyannis, €0assachusF,,tt§ 02C-09 Fizz ............... �3 THE � BOARD OF F LEALTH Ts 4 1U ..1 own .....OF.. CO3m-5 Pt ApplirFa#ion for Uhipoii al Vorka Towitrnrtann Famit Application is hereby made for a Permit to Construct ( ) or Repair (.V.4 an Individual Sewage Disposal System at: I ...3. sx�►�1:.... .& �!,tl��.a-------------- ---•--------••----.................-•----•-----............-------•-...................----------- Location-Address o Lot N LuH�t.� ....Fr_ n -•--------•.....................................•- t!1 er.S?� .l�.u�¢T. si�a ��.........--------------•-------- - Owner Address wAss.. s�_�o.....................................•..----........................... Q._. gin.._ .-,..s ._y„I�_.r�c� +.............--- ,., A .. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ............ No. of persons............................ Showers Pa YP g -----•-•-------- P ( ) — Cafeteria ( ) A'' Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow----_---------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length-............... Width................ Diameter-___.___.__•-_- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-•__-__-___-_-__.- Diameter.................... Depth below inlet....._.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..................•---•----•.......------•-••---•---•--•---•-•----•-•••--- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water--_-____________---___-. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--•-•-•••---•--------------------•-•---•---............................................................................................................... 0 Description of Soil........................................................................................................................................................................ W ----------=•----------•----•-------•...................•------------•-•------•----------•--•---•.....------•---•------------•••---------...........------•---••----- ------------------------------- - U Nature of Repairs or lterations—Answer wen applicable._4A ... .-Sde�2 tc. ...160O aj.JL&A Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLE y g g p y 5 of the State Sanitary Code—The undersigned further reel not to lace the system in operation until a Certificate of Compliance has been issued bythe board of health. Signed--- 3 . ---- ....... _ Date Application Approved By.............a ---- ,.�.+""� ----------- Date Application Disapproved for the following reasons:---------•----------------------------------------------------------------------------------------------------- Date PermitNo..... $.r.. ./.............................. Issued....................................................... Date yd 1..... Fmc...:~........ No.- ..`9..-..._._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... ....................OF......................... ...............----------------•---------------................. ApV irafton for Bhipasai Works Tomitrurtiun erntit Application is hereby made for a Permit to Construct ( ) or Repair (',' ) an Individual Sewage Disposal System //at: .- ^ ...............................................:..............................•---......_..•••--• •......•----...............-•-----•-•-•••-•------.....-----........_........_............-•-•-•--- Location•Address or Lot tio. itr.�EP �e P, .... .•. •---••........ . Owner I Address (� F. .1. ................................................�o cc ( ,G � V r . Installer Address d Type of Building Size Lot............................Sq. feet 1-4 U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria dOther fixtures ------------------------------------•-----------•-----•-••------•--•--------•---------------.._..•-••-•-•-•••-••--•••--•--•------•-•-......••-•-••... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width-................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...__....-..__-_-.__.... Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._--...._.__-_-._._..- a ----•-•-------------------------•----------•-•......---...-•--•--•-•-•--•-•-.-•..............•---•-......................................................... ODescription of Soil........................................................................................................................................................................ x U •-•--------••-••--•--------•-•---••----••----------•--•-•••••-•-•--•-••-•--••••-•••••••--------------•-•---••-•-•----•••-••-----•....._...--------•----•-...•••. •••---•-••--••-•-•--•-•----•-•-•-••--- w .............--------------------------•--••••••••----------------••---•------------._...--•------•--...................--------------------•--••--•----••-----•••-•••-•......--•----•--•----•--•---- UNature of Repairs or Alterations—Answer when applicable..=..''.: .__� _.-►'''?r•.^_:.P 5 c r+�c 'j, .L I rlc? r" ; l_ c l L f• . tt,ra�! •---------------------------------------------------•----•--••--•-•--••-•--•••-•-••......_.......-----••••--.......------....----------------....•--•••--------•••-••--------•----•--••...........__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T1 1E y g g p y 5 of the State Sanitary Code—The undersigned further reel not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. Signed. . .. ..."�._ '............. j../.' <; � Application Approved BY-•-••--•-••• 1 �,`". --. ........................................C. Date Application Disapproved for the following reasons----------------------------••-------•-------------------------•-------------•-------------------------.......... -•••••-•-•--•-••----------•-•-••-••----•---••--•-----------•-----•------••----••........--••--------•--•..............••--•---••-......•---•----•---••--•------•--•-•---•-----------•-•---•----••--•---- Date PermitNo.---- :.:LIP/............................... Issued....................................................... Dsxe THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................0F........................:..��..`................................................... 0rrtifiratr of Toutph attrr TH1SSLO CERT FY, That the Individual Sewage Disposal System constructed ( ) or RepairedbY------------_-� - .f..............................................................----•------•........•-- ----•••--••..........-••••-•...........-•-•-••----------•...--•--•--•••-. at..••-------- ," ram` . ...... has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - 1/0/ ...... .......'............................OF................ ..�'��-......................................................... dam_ Noll .............. FEE....._.................. �i��t�an nrk ��rn�#rlta�i�rn rrntti Permission is hereby ranted...... .. to Construct ( )ag r Repair P<) an Individual Sewa a Disposal S,�rstem at No.............. ......J W 4�.. �'G U ea-jee .,rLGx=t.. . Street 00 as shown on the application for Disposal Works Construction Permit N .8. ..... Dated.......................................... ............................ � Board of Health -i DATE...................7.`. o ..?. ............. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS