HomeMy WebLinkAbout0016 WEST WIND CIRCLE - Health 16 West Wind Circle
s - Osterville P
A 121 011002
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THE COMMONWEALTH OF MASSACHUSETTS Yes
" PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4pYILatIDTC for -MI8p0saY *p8tP1Yl CDttBtCULtIDYY VPn1tIt
Application for a Permit to Construct Repair U ade Abandon �
pp ( ) p (i/�pgr ( ) ( ) ❑Complete System Individual Components1++
Locati ddress or Lot No. 2/ o Owner's Name Address and Tel.No. f
C_-.:
t �+
Assessor's Map/Parcel
Ins ler's Name,Address,and Tel.No..5Z*J'- 7TS= �d�-' Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 1v 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)
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 by this Board of Health.
Signed - Date .�
Application Approved by i Date
Application Disapproved by Date
for the following reasons
Permit No. �� 2 Date Issued �I
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' THEPOMMONWEALTH OF MASSACHUSETTS Entered;ncomputer: Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTAKE, MASSACHUSETTS
CF ftplication for-Misposar Opstem Construction permit
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Application for a Permit to Construct( )' Repair V"Y/Upgrade( ) Abandon(I) ❑Complete System ndividual Components
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Location Address or Lot'No. Owner's Name Address and Tel:No.
mac' Cry%�rc� c�i OSFcv�v%%� ✓G�ic�sc/ L�6�avc
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No..Sod= 7�.3=��'�3— Designer's Name,Address,and Tel.No.
Type of Building: t
Dwelling No.of Bedrooms Lot Size sq.ft. 'Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria(
Other Fixtures
Design Flow(min.required) A gpd Design flow provided /�— gpd
Plan Date Number of sheets. Revision Date J,t�/r�
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alteratio s(Answer when applicable) %7-- .
� _/_..� �/ /7�.�G°' -S s�' S/t"Y,rli J.o� !��/.Y`- ' r�isr ;�✓r%"
Date.last :ins ected
I. Agreement:
z#
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 by this Board of Health.
r .r..
„ _ _
Signed ,..—�, ,.---'��. ..�" Date r•3'�`J`'�.�/
Application Approved U'y e. I'' Date
Application Disapproved by Date
for the following reasons �.
Permit No.' �� 2 � � Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
( (Certificate of Compliance
THIS IS TO CERTIFY,that the On-site
Sewage
Sewa a Disposal system Constructed Repaired Upgraded
( )
Abandoned( )by
at �� /i✓/Ssr /L i H 0 3'7�`"PG t_-
� ,� ��,� has been constructed in accordance r
with the provisions of Title 5 and the for Disposal System Construction Permit No.Zo1 f`��S dated / ((1d
Installer Designer
#bedrooms JL f 1/} Approved design flow {�J j, and
- ww tC ,
The issuance of this pe it hall not be construed as a guarantee that the system ill ct o as des ed.
Date ( x I Inspector 1,)7
Kam!
----------_
No. Z �^ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
1� Misposal *pBtem Construction 30Ermit
Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located at 16- /�,r►�s� ��_,;�.� Gii'; /� �riijY
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:Construction iliust completed within three years of the date of this permit.
Date F J�a 7,; ( Approved by,
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IN ASSESSOR'S MAP& LOT �O {
INSTALLER'S NAME&PHONE NO. 7
SEPTIC TANK CAPACITY + Co -
LEACHING FACILITY: (hype) CC
(size)
NO.OF BEDROOMS M .
B UILDER,OR.OWNER
PERMITDATE:
COMPLIANCE-DATE: . -
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r$ - Feet
Private Water Supply Well and LeachingFacility
ty (If any wells exust s on site or within 200 feet of leaching facility) Feet ?'
Edge of Wetland and Leaching Facility(If any wet exist A
within 300 feet of leaching facility) s Feet
Furnished by -f( `
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Town of Barnstable
Inspectional Services Department
A`"BM
MA ' Public Health Division
RS.
1639.
200 Main Street, Hyannis MA 02601
G
Office: 508-862-4644 r -
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7021 0350 0000 1549 3600
June 21, 2021
LEBLANC, MICHAEL J
16 WEST WIND CIRCLE
OSTERVILLE, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 16 West Wind Circle, Osterville, MA was inspected on
05/27/2021 by Michael T Bisienere, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Distribution box has major decay and needs to be replaced.. I!,
You are ordered to repair or replace the distribution box within one (1)year from the
date you receive this notification.
Failure to repair/replace the distribution box within the deadline period will result in
future enforcement action. .
PER ORDER OF TH BOARD OF HEALTH
omas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\16 West Wind Circle Osterville.doc
t�t
Town of Barnstable
BARMASs l.G� Inspectional Services Department
MASS
\ A 1 e
�lE'A79•639. R Public Health Division
200 Main Street; llyannis MA 02601
1 human A Mc�.c;ui.� I I1,
f Nll.c 5U8-862-404
i:Ax 5u8-79U 6304
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
Code §360-44 and Title Vi 310 ('MR 1 5.000)
An "x' marked in the Li Is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
o Discharge or ponding of effluent to the surface of the ground
ing more than 4 times during the last year not due to clogged or obstructed
LD Pump
pipe.
I_I Back, of'sewage into the house due to an overloaded or clogged SAS or cesspool
k w
o Structurally unsound septic tank or SAS
ONE 1 YEAR DEADLINE CRITERIA
n Static liquid level in the distribution box is aho\e the outlet invert due to an
overloaded or clogged SAS or cesspool
A portion of the SAS. cesspool. or privy is below the high groundwater elevation
A portion of.the cesspool is located within a lone i to a public well
A purtic,n i,i the cesspool is located within SU font of a stem}'►rise i11 flee ��ater'analysis
with no acceptable wale► quality analys►s. (,I h► 1 p
indicates the well is free from pollr►tion).
-I'Wo YEAR DEADLINE CRITERIA
Single Cesspool
1jl�. .-conditionally passed systems" (broken cover._ relocation of a Pipe, relocation
of a drivewa due to I l i O components. etc)
_;. I.e ►thing facility \y*Ih standing liquid level at or above the ins ell pipe (per
Code ;60-20 h)
() HER
Repair deadline: -
0\SEPTiC•DEADLINES 10 REPAIR FAILED SYSTEtAS ooc
Commonwealth of Massachusetts
t Q1- 011,60C
�n Title 5 Official Inspection Form
5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F
16 West Wind Circle `'
Property Address C aT
Michael Leblanc
Owner Owner's Name /
information is required for every Osterville V MA 02655 05/27/2021`
_
page. City/Town State Zip Code Date of Inspection
-t II
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 14- L+1(0
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
key. Company Name
52 Rivers End Road
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 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
Lzti���� 05Z27120�21
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
cam, Commonwealth of Massachusetts
1n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c 16 West Wind Circle
V
Property Address ,
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
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:
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
16 West Wind Circle
V
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.): t
❑ 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
c Commonwealth of Massachusetts
7 Title 5 Official Inspection Form
= �i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
page. Cityrrown State Zip Code bate 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:
This 2 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a precast
leaching pit with stone.. At the time of the inspection the D-Box had major decay. I recommend
replacing the D-Box.
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
El ® 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
cam, Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�n
c !� 16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
page. CitylTown 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 '/2 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
El ❑ 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
16 West Wind Circle
V
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
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
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?
® El 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)]
t
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
r ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
v� Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 22 plus
GP
Description:
Number of current residents: 2
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d town water
9 ( Y 9 (gp ))�
Detail:
In 2020- 189,000 gallons were used and in 2019 - 92,000 gallons were used.
Sump pump? ❑ Yes ® No
r
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
(n
� 16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
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
+ Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 , 05/27/2021
page. City/Town 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 21feet
Material of construction: w
❑ 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.): .
Water was flushed and came freely.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
E
Commonwealth of Massachusetts
M1 ,p Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
16 West Wind Circle
v�
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osteryille MA 02655 05/27/2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
•Depth below grade: 14"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: H-10 1000 gallon
,
Sludge depth: 31-
Distance from top of sludge to bottom of outlet tee or baffle
33"
V.
Scum thickness
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
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 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
i
Commonwealth of Massachusetts
�y p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e � 16 West Wind Circle
Property Address
Michael Leblanc
Owner Owners Name
information is required for every Osterville MA 02655 05/27/2021
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):
h t r
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c � Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
z
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16 West Wind Circle
v
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
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
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..):
At the time of the inspection the D-Box had major decay."
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
���,e� 16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
page. City/Town 4 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
i
Type/name of technology-
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
inquired for every formation is
r,. Osterville MA 02655 05/27/2021
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 no visible failure criteria was found.
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.):
II
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
+' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville MA 02655 05/27/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
i
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.):
• P
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
I e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
informationis
reequirequired for every Osterville MA 02655 05/27/2021
o
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
3 r
Pr
"L
05.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
'T Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
Property Address
Michael Leblanc
Owner Owner's Name
information is required for every Osterville . MA 02655 05/27/2021
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 groundwater elevation:
I augered a hole at a lower elevation and 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
i-
Title 5 Official Inspection Form
11 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 West Wind Circle
Vj
Property Address
Michael Leblanc
Owner Owner's Name
information is Osterville MA 02655 05/27/2021
required for every
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed &Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
P ,
No................ . .. �$. .��.............
D
Y THE COMMONWEALTH OF MASSACHUSETTS
(I J� BOARD OF HEALTH
0_1 ......as a./.7 4�_ . _1&. ............
Appliration for Dhipmal larks Tongtrn.rthin Prrutit
Application is hereby made for a Permit to Construct (7'�Y or Repair ( ) an Individual Sewage Disposal
System
.. ----- ...........
Loc n-A dres' s or Lot No.
•-- ---- - -------------
Owner Address
'Installer Address -
'Y U Type of Building Size ---Sq. feet
- �.. Dwelling—No. of Bedrooms......._..3............................Expansion tic ( ) Garbage Grinder ( )
a Other—Type of Building No. of persons ------------- Showers Cafeteria ( )
Other fixture
--------------------•-------------------------------------------------••••• •••••••••-••...-•••••......••....._•---•-
W Design Flow..............._. _............._......gallons per person per c}ay. Total daily �9w.._.... _ ..0-----•--••••••--.---_ga11`pns.
WSeptic Tank—Liquid capacity�¢�Qgallons Length-------�./.... Width...��---- Diameter................ Depth---4---------
x
Disposal Trench—No..................... Width•--•__ ------------ Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No._._._.../--------- Diameter........ --�--•- Depth below inlet...... ......... Total leaching area...4M...7..sq. ft.
z Other Distribution box (+ Dosing tank ( )
Percolation Test Results Performed by-----------••••-•-- ..................................................... Date........................................
,.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................
(i Test Pit No. 2................minutes per inch Depth of Test Pit...�_.3+.... Depth to ground water./j/0 //#__21554?
0 Description of Soil............ °..�..----...iCL�Ll- ,/-� ..l
------�4 .l---���---•--� f"-�--......--•--..
V -----------------------------------•.......-----------..........----...••••...............••...
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-------------------•-------------------•••••••••••••-••••••••••••-••••••••••••••...........-•••••-•-•••---------------•----•••---••••••••-••--•-------•-•••--•••-•••••••--••--••----•...._...--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITi LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sued by the board o health.
�... --------------------•--
Date
Application Approved By..eelowing
Date
Application Disapproved f oreasons---------------------------------------------------------------------•----------------------...........•--•••----
.................•-••-•••.....................-•••-••••••...........•-
Date
PermitNo......................................................... Issued.......................................................
Date
i f 00
11F
No.................f.. _ Rs..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
o
Appliration for Disposal Works Tons rn.rtion Vamit
Application is hereby made for a Permit to Construct"( ^) or Repair ( ) an Individual Sewage Disposal
System at .. ...: : : .............. 2 .............
._. .Q........ .
Lo on-Addressor Lot No.
.._...-- ��- - G .,�''. --------------- -------------
Own r
Address
Installer Address
Type of Building Size Lot.
��,t 3-1.X....Sq. feet
Dwelling—No. of Bedrooms........ .r__-----------------------Expansion ttic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons.______._______________ Showers ) — Cafeteria ( )
Other fixtur --------•-----------••------------------
Design Flow.............
W
_ _ -_-_ gallons per person per Jay. Total daily w...... ._.________ ons.
WSeptic Tank—Liquid capacityl _gallons Length__.._: ...... Width__S7/c____ Diameter________________ Depth ----_____--
x Disposal Trench—No_ ____________________ Width_____e............. Total Length......._..___:. Total,leaching area__...._.............sq. ft.
Seepage Pit No......... Diameter...... .__ Depth below inlet___._'f____.Total leaching area_ ✓y _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 _
Test Pit No. 2................minutes per. inch Depth of Test Pit 1__3_ ..... Depth to ground water'A_1��r
x ----- --- ---
________----
D Description of Soil_..------- - � .�_{ _ :-.---61 jC7 ;!' t f, --J
V •----•----•------------------------------•-----•-----------•---•--------------••-----------____-------•-----------------•-----------------------
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------------------------------••--•----------------------•------••----------------....----...._...-----•--------------------------•------------------------------........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'ssued by the board health.
_....
Date
Application Approved By.. "•..
,✓ Date
Application Disapproved f o lowing reasons:----•-----------------------•-----•---------------------------------------------•-------------•=--•--••---•_._..
----------------------------•--------•-----•-------------------••••------•-----......---..._...----...--------•--..._....------•------•---•••--•------•---•-------------•----•-----•---•-•------......
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
W.0.11,....-OF........ _...
(9rdifi.ra a of"...9um li nrr
THIS IS TO C RTIFY, That the Ind' dual Sexage'!''Disposal System constructed '") or Repaired ( )
Installer
at ' ::- �-'}� ---_---_-----
has been installed in accordance with the provisions of T e State Sanitary Code as described in the
application for Disposal Works Construction Permit NO.....
O•--. ......... dated ------ ----------------------•-••-------•
THE ISSUANCE OF_THIS CERTIFICATE SHALL NOT BE CON TRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ _______•-••-----••-----••--------•--- Inspector........ ="
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .OF HEALTH
No......................... FEE.......................
Disposal lVorks , n r uan err i
Permission is hereby granted___________ ___ ,> " •----
to Construct or.%Repair ( ) an Irylividual Sewage,
at
System
i "
s
-o ... ... .. ..... �
Street
as shown on the applicat' n for Disposal Works Construction Permit No.._ I ------ Dated..........................................
.................... . •---- ------•---------------..__....-----•.......-----••----
�-"`
DATE._ Board of Health
_�fd.__. :---- --
FORM 1255 A. M._SULKIN.,INC.. BOSTON
i...0 A T 10 M flap /Nrl' Y (� S E W A G P M I
VILLAGE
6s ey.o,
I v S T A LLER'S N A mE ADDRESS 1
S er ® TA eo ho �/�A
8 U I L D E R OR D� ER
LeoN�
DATE PERMIT S S U i D A010 9_
DATE C0MPLiANCE ISSUED
�d
�..
ce TOWN F13ARNSTABLE
�M1^''"�TION Y SEWAGE #'
VILLA A46LVU I ASSESSOR'S MAP&�LOTT vo
INSTALLER'S NAME&PHONE NO.
n 1�
,( SEPTIC TANK CAPACITY l L ' + i/1 i1E ' T4
LEACHING FACILITY: (type) (size) LQ
'NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wet exist
within 300 feet of leaching facility) - r , Feet
Furnished by /► �� �3`
MCI �
�3 n-
A Gg0
PA zo
66 30
(bC�31
;I
'1 1 69 2
RECEIVED
COMMONWEALTH OF MASSACHUSETTS NOV 2. 0 Z003
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI STowN of BARNSTABLE
HEALTH DEPT.
s DEPARTMENT OF ENVIRONMENTAL PROTECT
m �
ti �2 f
MAP n
^M 5�0v0 PARCEL L 0_ 11.
'LoT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
1> CERTIFICATION r
Property Address: 16 WES)WIND CIRCLE OSTERVILLE,MA 02655 `J
Owner's Name: CAROL GEMELLI
Owner's Address: 607 BROADWAY HANOVER,MA 02339
Date of Inspection: 10/29/03
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 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:
X Passes
_ Conditional] asses
_ Needs Furt valuation by the Local Approving Authority
Fails
Inspector's Signature: ,t Date: 10/29/03
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspect n. 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 f
sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. .
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
r
****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 IncnPrtinn Fnrm
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO_ N FORM
PART A
CERTIFICATION (continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
n/a 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: n/a
n/a 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: n/a
n/a 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: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
C. Further Evaluation is Required by the Board of Health: ;
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b).that the 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 n/a
"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:
n/a
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
Check if the following have been done. You must indicateN"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?4
_ 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.
f .
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)]
. I
S
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
D. System Failure Criteria applicable to all systems:
You muss 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 %2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
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
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
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.
d
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART C
SYSTEM INFORMATION
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220
Number of current residents: 0
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): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last
),<\` Q(last 2 years usage(gpd)):-W 02'I Z��pDU
Sump pump(Yes n NO `l 12�» tiQ e C C
Last date of occupaancy:y:� l -
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO r
Non-sanitary waste discharged to the Title 5 system(yes or no)! NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: YA* 00�- \r\� "Af P-e
Was system pumped as part of the inspection(yes or no): NO F
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
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): n/a
Approximate age of all components,date installed(if known)and source of information:'
20 YEARS PER OWNER'
Were sewage odors detected when arriving at the site(yes or no): NO
C
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
BUILDING SEWER(locate on site plan)
Depth below grade: 22"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage, etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 1011"
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness: 0"
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: 18"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
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: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
i
R
Page 9 of 11
„ p
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE, MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
b ,
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: .
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: 0
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure,'level of ponding,damp soil,condition of vegetation, etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. PIT WAS EMPTY AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD
MORE THAN 33" OF LIQUID IN IT. BOTTOM IS AT 101".
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a `
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.):
n/a
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
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.
w
fA
its
�9
50
t
Page 11 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 WESTWIND CIRCLE OSTERVILLE,MA 02655
Owner: CAROL GEMELLI
Date of Inspection: 10/29/03
SITE EXAM
_Slope
_Surface water
Check cellar
_Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER-12+FT.
11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. City(rown 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:
forms When A. General Information t �I
fillip out f I "I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
H.P.S.
� Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774-274-2581 12866
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 tenance f on
sewage disposal systems. I am a DEP approved system inspector pursuant two ection 1.W40
Title 5(310 CMR 16.000).The system: + �a
® Passes ❑ Conditionally Passes ❑ Fpj +
❑ Needs Further Evaluation by the Local Approving Authority
l
9/10/14
Inspector's Signature Date -
The system inspector shall su a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 ays 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.
t5ins•3/13 Title 5 Official Inspection, rm:Subsurface Sewage Disposal System•Page 1 of 17
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10114
page. Cityrrown State 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:
® 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:
Tank in good cond. tees in place liquid level is at bottom of outlet pipe. Tank does not need to be
pumped at this time. Dbox clear of solids and carry overs no visable cracks or leaks. Leach pit is dry
at time of inspection. there is a high water line 37" below invert pipe. no indication of liquid level being
above that point.
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.
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):
t5ins-3/13 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
�M 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ 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):
C) Further Evaluation is Required by the Board of Health:.
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health; safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the 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
t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) '
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 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.
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 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
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® 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 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 forma
❑ ® 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) 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 D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large 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.
t5ins•3/13 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
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is Osterville/Banstable Ma 02655 9/10/14
required for every
page. Citylrown 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
® ❑ 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?
❑ Z 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)]
D. System Information
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
40,000
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: '
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M s 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® 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)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):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Ostervil,le/Banstable Ma 02655 9/10/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: 26'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan): .
Depth below grade: 1.5'
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth: 211
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 16 West Wind Circle
Property Address
Hunter
Owner Owners Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? tape and 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.):
Grease Traplocate on site plan):
( P )
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
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
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 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.):
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
dry pit is functioning good faint water line 37" below invert to pit
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ti 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
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
t5ins•3/13 Title 5 Official Inspection Forth: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
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityrrown 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.):
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Citylrown 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
❑ drawing attached separately
0
J*U
g�
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
a
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M , 16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
-Estimated depth to high ground water: 20+'
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:
used asgs topo maps
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 West Wind Circle
Property Address
Hunter
Owner Owner's Name
information is required for every Osterville/Banstable Ma 02655 9/10/14
page. Citylrown 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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