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HomeMy WebLinkAbout0116 WEST WIND CIRCLE - Health 116 West Wind Circle Ostervlle = 1.21=011-010 `r I I ;., Commonwealth of Massachusetts /o�/-�//� QjD / OW— L. 1 � Title 5 Official Inspection Form ,rI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liguori Owner Owner's Name r ' information is ✓ ° required for every Osteryllle MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection 'X� 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. A. Inspector Information 6Zo- 13OR9 Shawn Mcelroy Name of Inspector s Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty 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 7-12-19 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 Commonwealth•of Massachusetts r Title 5 Official Inspection Form c•il Subsurface Sewage Disposal System. Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is Osteryille MA 02655 7-12-19 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:' ® 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: System is in good working order with no sign of failure. 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 Commonwealth of Massachusetts r� Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville • MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ON ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ON ❑ ,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 ON ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following.for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form, Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is Osterville MA 02655 7-12-19 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 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area,(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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 r� ,w Title 5 Official Inspection Form i�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town State Zip Code 4 Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to- Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 7-2019 Last date of occupancy: Date 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 l� al w. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `rI 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town 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: N/A 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 c Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form I.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquod Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 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: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 161 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 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 de Sludge the 12° p Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form YIM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l fr: 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osteryille MA 02655 7-12-19 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.7/26/2018 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 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 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.): Good condition with water at working level and no sign of back-up from pit. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 s Commonwealth of Massachusetts 3 Title 5 Official Inspection Form YrM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Sri,•T,rr%> - - Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ' ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type ,. ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liquori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 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.): Leach pit in good condition and empty at inspection with stain line at 12" off bottom of pit. 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 r� Title 5 Official Inspection Form C�'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 116 West Wind Cir r Property Address Marco Liguori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form i61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Cir Property Address Marco Liguori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 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 0 i■■.�W�I■■IYY C�? d3 .....uw..�� ear, f■� 'w .,b �o,r■r� - 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 Ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 116 West Wind Cir Property Address Marco Liguori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 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: 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: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 cam` Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � .:_ >`` 116 West Wind Cir Property Address Marco Liguori Owner Owner's Name information is required for every Osterville MA 02655 7-12-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson - Owner Ownees Name information is Osterville MA 02655 April 18, 2012 required for every _ �, . page. Cttylrown 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 fortes A. General Information - . on the computer, I use only the tab 1. Inspector: I . key to move your cursor-do not David D._Coughanowr, R.S. use the return - -Na - - key. me of Inspector Eco-Tech Environmental Company Name 43 Triangle Circle Company Address -10 A H Sandwich MA - 02563 Cityrrown . . State Zip Code 508 364-0894 1328 Telephone Number License Number. B. Certification certify that I have personally inspected the sewage disposal system at this address and thatthe 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ; 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 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:DER 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 undrr_,t.he conditions ofuse at that time.This inspection does not address'how the system will perform in the future antler the same or different conditions of use. NO tsins•1010 ifl 5 Offidef inspecOon Form:Su urfeCos eweaLvw Spat.•P of 17 Commonwealth of Massachusetts ' Title 5 . fificial LnS ecti+�n Firm p Subsurface Sewage Disposal System Form Not for Voluntary Assessments; 116_WestWind Circle Property.Address 5tanton.'and Marcia Abrahamson Owner Owner's Name information is required for every 'Osterville MA 02655 Ap,riJ 18, 2.012 page. CityTTown state Zip Code Date of'Inspection B. Certificati.on (cons:), Inspection:Summary: Check A•,B,C;D or E l always completb;all of.Section,D. A) System Passes: I have not found any information which indicates that•any afihe�fallure criteria described in 310 CMR`1:5 303 or m 310'CMR 1,'5:304 exist Any fa lure,criteria_not'evaluated are indicated below: Comrhents Inspector's Note==> The septic system deseribetl herein'is d'eemedto.p:ass this Real Estate'Transfer Inspection if it tloes:not meet any of the;fallure'cntena enumerated in Section on pi igeg,*B,The scope of this;Inspection isilirnited to health and envlrbhimental compliance antl tf eseptic system has been;ovaluated according to the,,conditions observed on the.daytit,was inspected. No estimate,or. guarantee of-system longevity is madeor implied by a passing-determination: Removal of beinder is.re-commended a,) System Conditiohalfy Passes: ❑ ,One or more.systerr components as described to he "Conditional Pass"section need to be replaced,or repaired: 11' system, upon completion of the replacement' repair, as"approved:,by the Board of Health, will pass: Cheek the.box for",yes "no° or"not determined" (Y,:N; No- for the following statements: If"not determined;"`please;explain. The septic tank`is metal and ove'r20 years old*or the septicaank (wh'etherrnetal or not) is.structurally unsound; exhibits subs}tantial.ini ltratio,n:or exfilfiration•or:tank'failur'e is'imminent.:'System will,pass inspection if'1he exsting'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 Ceitlficateof .Compliance indicating theit`the tank is less than 20 years old.is available. ❑, Y ❑ N_ ❑ ND (Explain below) 5.ins•i vib Titlo 5`Official Inspection Form:'Sub'suNace Sewape'UisposalSyslem•Page`2 of 1X • .�...,...r,�.,..,,.�x.•„¢.,;f,aagr�••.,�, a.,.yt;F y ter"°�"""" �.-«'.�,'.��"""..- --7,. _ _ Commonwealth of Massa:chusettis Title 5 Official In e _�tlort .dorm Subsurface Sewage;:Disposat=System Form Not for Voluntary Assessments! 116 WestV1lind;Circ1e Property Address Stanton and Marcia Abrahamson. Owner Owners Name information is Osterville MA 02665 A nl'1,8, -2 required for every p page. Clfy7Town ;State `Zlp;Code Dafeof Inspection B, Certification, B). SystemConditonallyPasses (cant;:)." ❑ Observation of;sewage backup or:,break.out:or highstatic-water level',in the distrh io:i box due, to broken;or obstructed,'pipe(s):or due fo a broken,seftled or uneven,distribution box; System will pass inspection if(with,approval of Board.of Health): broken pipes)are replaced ❑ Y ` ❑ .N ❑ ND`(Explain below}: ❑ obstruction is removed; ❑ Y ❑: N El ND(Explain below): ❑ tlstribufion,tiox`as leveled orceplaced. ❑'Y ❑ N ❑ ND;(Expla2n 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 tha-Board-of Health): ;broken pipe(s):are replaced. ❑ Y ET ❑ ND(Ezplain'below) ❑ ;obstructiion is.re-moved, ❑. Y ❑ N ❑ ND (Explain below):, C) Further Evaluation is Required`by the Board of Mealth.; ❑ Conditions exist w pc,require fuither evaluation,by<ahe'Board,of Health'in order`to determine if the,systen is.failing".to protecf public health,safety"or the envirorimerit _. 1 System will,pass unless-:Board of Health determines m accordance with M CMR 15 303(I)(4)1,thait the system is not functions Ig in a manner'which will protect public health, afety and the-envlroriment, Cesspool or privy is within 50 feet�of a `surface water ' ❑; G:esspool or privy is within 501:feetof`a bordermgvegetatedwetland ora_salf marsh t5ms '1:7110 Title 5 Olfcial Inspection Form;,Subsurface Sewage oisposal%$yslero' Page-3'oP.17 Commonwealth of Massachusetts - Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owners Name information is Osterville MA . 02655 Aril'18, 2012 required for every P 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 mannerthat protects the public health, safety and environment: El 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply: ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from 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 Wggered.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 orponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El 1K Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool11 - ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 o117 ate. a,}, s s + f' _. --a• xr Commonwealth df Massachusetts' Tittle 5 Official, Inspection1- F®rrn _ Subsurface Sewage Disposal System Form:-Not forV,oluritary.Assessments 11&WVe5t"Vllind Circle. .. : Properly Address - . Stanton and Mania Abrahamson: Owner Owner's Name information is required'for:every Osterville: JMA 02655 April 1`8, 2012 ' . cltyrrown State::' `Zi Code - Date of Iris eotiori page. P' P B. Certification (cont..} No`. Required purripmg'more than 4 times in the last year NOT due to clogged.or ❑, _ g6, ijted pipe{s}.Number:of tirneS pump°etl -_ ❑' Z;� Any porbon,ofthe:SAS, cesspool.or privy.is, elow high'ground:water elevation. Any portion of.cesspool or privy is`within`100 feef'.of a surface;water,supply or" ❑ �' tributary to aa,urfacewp er supply,; ❑ ® , Any portion of„a cesspool.or,privy is twithin`a`Zone 1 of a public well:; ❑ >qny, portion of;a cesspool or'pnvy is`within 50 feet of a private water.s'upply"well.. ❑ Any portion of,a cesspoo(or privy is,less than'100 feet but greater than 50 feet 'from a pn�ate;water�supply:.well with no acceptafjle v+iater qualily,analysls. [Tfi:s system passes if the wel,l;wateir analysis, performed?at a DEP certified laboratory-,forfecai,coliform bacteria 'Iatlicates.atisent 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<,analyss Wand chum Of;custody must be;attached`to this,form:] _ esspoosvingafa❑ Q> he system wth a;"de-Wflow of 2000gpd. 10,OQQgpd : The system fails. I",have determined that one or more of the above failure ., criteria exis#as described in:310 GMR 15 303, th.ereforb:,the-system fails The ystern "er should contact therBgard of Health-to determine,what will be necessary tq::correctahe failure: E). -t arge,.Systems To be considered a large system the:systerm ii6 serve,a�"facility,with a design flow of 10,000 gpd to 1:5;000,gpd. ;For large systems, you mustandicate either"yes"or 'no"'to each of thefallowng, in.addition;to the uestioris in Section.D. Yes' No .0; ❑ the system istwithin 400 feet of a surface drinking watersupply: ❑ ❑ the system -§within 200 feet'of a tributary to a surface drinking watersupply, the system is,located"In,a nitrogen sensitive area:{interim Wellhead Protection o❑ ❑ Area-i_IWPA; r a Ma pp Il of a ublic water supply.well' pp p If yoia have,answered;"yes,to any.questior in-Section E the system is.;eonsidered a significant threat; or answered."yes,. in SectbW above thelarge.systemthas,.failed The-.:owneror operator of.any large; system,consitlered'a.significant threat under'Section'E or:,failed,under?Section`D'shall upgrade the. systern;in accordance with.310 CMR 15.304 The:system owner shouad contact the appropriate yregional offi, of the Department: _ t5ns 11110 — Tine @,Official InspeeUon Form.;S.uhsur(aee;Sewage disposal Systein;,Pago 5 V'l7` Commonwealth"of Massachusetts M; V Title 5 Official Inspection, Form Subsurface Sewage Disposa["System Form;:-Not for Voluptary-Assessments' � 116''Vlfest INInd Circle _ �- Property Address Stanton and;Marcia Abrahamson Owner Owner's Name; .information is required forevery Osterville MA - 02655.. aril 18,.2012., page. Cityrrbwn State;_ Zip Code: Date,of Inspectim. G. Checklist `Check if the following have been done. You.must indicate ', .es" or."no" as to each,of,the foIlowin Yes: No., it ® ❑ Pumping,information was provided by 1heowner, occupant, or Board of Health ❑ Were any of the"system.c0 ponents pumped out'in".the'previous two Weeks?: 0 H'as the system received"normal flows in the preu,ious Mo week period? Have larg6,v olumes:f-,Water,been introduced ' the system recently or as part of' El Mthis,fnspection? 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? 0 ❑ Was the site inspected for signs otlbteak out? ❑ Were<all system:components; excluding the SAS', located on site? 0' ❑ 1Nere the septic tank manholes uncovered,,,opened,'and the interior of'the,'tank inspected for the.condltion of the baffles or tees,�rriaterial of construction; dimensions,,depth ofliouid,depth of`sludg(? and".depth-of scum? Was the facility ow ner,(and;occupants it different#rom owner} provided with 0 El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil:Absorption SotemISAS) on-.the site"has been determined based bn; El Existing information., For.example a plan at the 6'oard.of"Heal th:<- Determined in.`the field (if any of th"ilure criteria related to Part Cis at issue approximation of di.stance is unacceptable};[310"CMR 1`5 302{5)J D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of"bedrooms'(actual). 3 DESIGN flow based on-$10CMR,1`5.203(for.example"'110rgpd x#of.bedrooM` 33Q"g I t5ins 11110 Tine 5 CIMdial Inspeclian Form,',Subsurface'SeWgge`Oisposal;5ystein•Page 6 of 17` Commonwealth of Massachuset#s Title 5 Official Inspection Form... . , i Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments - 116 West Wind Circle Property Address - Stanton and Marcia Abrahamson Owner Owners Name information is Osterville MA 02655 April 18,2012 required for every page. MY/Town State . . . Zip Code date of inspection D. System information Description: Number of current residents: 0 Does residence have a garbage grinder? = ® Yes ❑ No Is laundry on a separate sewage system?[if yes'separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usa e d 449 gpd g Y 9, (9p. }}: Detail: 2010,2011 Sump pump? ❑ Yes No Last date of occupancy: of de termined etermined Date - Commercialllndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day t9Rd)_ Basis of design flow(sestsipersons/sq.ft.,etc.): _ Greass trap present? -❑ Yes ❑ No , Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Watee meter readings, ifavailabie: 151ns 6.11110 :Title 5 OfCaal bspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwea'ith of Massachusetts _ Title 5 fficial Inspection F-orris Subsurtace Sewa a Ds osal S stem Form:-Not'for Volunta Assessments g. P Y ry 116 WestMind Circle Property Address -.Stanton and Marcia Abrahamson: Owner Owner's Name information is required forevery Osterville MA- 026551:: April 1$, 20-1:2 page. Clty/iown $late "Zip"Code Date;'ofanspection D. Syst Information ,(cost.). Last date of`occupancy/use; Date. Other(describe,be`low): I General Information Pumping Records,: Source of information: , . YEoNssytema umpedias of the ins ect ❑ion? 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 ❑ Oyerflow.cesspool Privy Shared system (yes:or no)(If yes attach previous inspection records, if.iany) ❑ :In novative/Alternative"tech nology. Attach a copy of'th'e current operation:and .'maintenance contract(to be obtained#rom'system owner)`and a copy of,latest inspectionof the I/A>system by system-,00erator.under contract Tighttank. Attach:a copy of ttie<,qEP ap;proval.; Other,(describe;): t5ins•11110 Title,somciarihspepllon.Porm;:Sutisurface Sewage Disposal,Splem•Page 8 of 17 Commonwealth of Massachusetts +� r Title -5 Off vial ,Insp coon Form Subsurface:Sewage DisposaLSystem Form -Not for Voluntary Assessments 116.Vilest Wind Cr•cle - ° P.ropeq,Address Stanton and Marcia Abralarrisoi° _ Owner. Owne's,Name information Is required for every. 'Ostervllle-. _ MA 02655 Apnl 18, 2012.. _ - . page. ty State :, 'Zip Coder Date ofan'spection 'a e Ci (Town D.System Information (coat ) •Approximate .age of:all components;date installed;(if known),and souce.of informat►on: Age: 25+ years Certificate.of Compliance issued"5/1611;986 (permit*i0" - _ Were.,sews e.odors detected when.; ' �site2' 9 g at.the- ❑ Yes Build n'g.Seymer(locate on,site plan) = Depftbelow grade: 2 feet Material,d construction. cast:iron 40 PVC T.other(explain): Distance from:pnvate water=supplynwell or 5uction;line - - - - feet Comments (on contlition jbijhts, venting, evidence of aeakage, etc Sewer line appears structurally sound withkno evidence;of leakage or backupinto dwelling: Septic'Tank,(locafe,on site plan) 15 Depth below grade:;. feet- - Material of construction concrete; ❑ metal. ❑ fiberglass;. ❑ polyethylene ;other`(explan) °If tank,is metal;list ag,e:; ears,1 Is age confirmed by "rtif Bate of'Compl'tance?°(attach: copy of certificate ❑ Yes.`'❑ No: Dimensions: 8 5'.x 5 x 6. 100.0;gailon ank Sludge;tlegth, 3 m: 15kns ]}1'J,10- Title 5 0016abinspeeGan Form;:Subsurfaee-S6gji&�isposal,Sysfo n' Page%9 0!17 Comm.onweAltf7 of;Massachusetts N Title 51 Off vital In-spection [Form: Subsurface Sewage=Disposal System F. Not for Voluntary Assessments, � N v 1.16 West Wind Circle Property Address ,Stanton and Marcia Abrahamson Owner Owner'sAahle, _. -- information is required`for every OsfeNille MA: Q2655'. April°18, 2012 page. City/Town State Zip Code Date of inspection D. System Information, (cone): 'Septic- Tank.•(cor t.) Distance from.top of sludge>to bottom>of outlet tee or baffle 31;in Scum thickness 2 in Distance from top of`scum"to.top of outlet-ttee or.-baffle 9 t ' Distance from bottom of scum to bottom otoutlet''fee or.baffle How,were dihienstons determined?, D,esign plan' Comments (on;pumping recommendations; mlef and,outlet tee or baffle.condition; structural integrity, liquid,levels:as related to outlet invert, evidence 6f leakage; Liquid level at outlet invert. Pumping not required at this,'time, but maintenance pumping iss recommended within and every"2 years Tank and•tees,appearstructura11 sound and functioning as intended. No•evldenc' of leakage in or outwas observed: Grease_°Trap (loca(e:on site;..plan) Depth:below grade: feet Material of construction: ❑ concrete ❑ metal; ❑ fiberglass ❑ polyethylene: ❑ other(explain):. bimensons: Scum thickness Distance from top of scum to top of outlet tee:or:baffle Distancefrom bottorriof=scu"m,to �ottom of:•outlet-tee or,baffle` Date"of last.pumping; Date. t5ins-11}t0 flue 5"016 1 Inspection Form:Subsurface Sewage'Disposal Syslam Page 10 or 17 k�' t, r , Commonwealth of Massachusetts.•` Y _ : Title 5ffici-al I'nspeti:on }F®rr�:. Subsufface Sewage.Disposal Systerr Form Not for Voluntary Assessments ` 116-VVest,VVintl:Crcle, Property Address �- !• . `: P - Stanton and`Mar-,a Abrahamson; Owner Owner's.Name information is required for every. Osterville MA Q265,5 April 18, 2012 page. cityrrown.' State; Zip Code; Date of,;lnspection D.;System Information (con!'): Comments (on pumping r-ecommendatiohs inlet andfoutlet'tee or baffle condition, structural integrity; liquid levels as'related;Yto..outlet Invert, evidence of.aeakage, etc - Tight or Hoidirig Tank'(tank must';ke pumpetl ataime of'inspectton) (locate.on site Depth:below grade: Material of construction. concrete. ❑ metal, ❑fiberglass: . ❑ polyethylene ❑ other(explai)): Dimensions: Capacity:. ' galloris - Deslgn Flow,: gallons per day Alarm present; ❑" Yes ❑ No Alarm level Alarm In working order: ❑ Yes ❑. No . Date of;last primping; Date; Comments (condition;of alarm and float switches,etcS); `Attach,copy.of current pumping contract'(requ1red) Is copy attached? ❑ 1'es; ❑ No: - Tllo 5 Olficlal Inspeclio_n;Form Subsurface Sewage f)isposal Syslom. ;Page 11'oi`:Y7 Corntnonwealth .of Massachusetts Title 5 off ici�al I'nspe�tion Form a Subsurface Sewage Disposal,System Form;-,Not for Voluntary-Assessments h,. 116-West Wind.Circle; Property Address, Stanton and Marcia Abrahamson Owner' Owner's Name information is required for every Osteryille. MA 02655: April 1$ 2012. page. CltylTown State; 71 C A Date of Inspection D. System Information (cont) Distribution'Box,(if;present must'b-e.opened) (locate on slte:,plan): bepth,of Uquid",leveiaboVe outlet'invert afoutlet'inverf Comments (note if box is level and.distribution to outlets:equ'al, any evidence of solids carryover, any. evidence of`Ieakage:into or'out of-box,etc.), D-Box appears structurally sound`and functioning as.intended.. No evidence;of'leakage,_inor out'was observed: Some solids'insump; Pump.Chamber(locate;.on site plan}':: Purnps in working order: ❑ Yes ❑ ;No Alarms in working order; ❑ Yes ❑ No Comments (note condition of pump chamber, condition of.pumps.and appurtenances, etc:): 'Soil Absorption Sys em (SAS) (loceitiaw site plan, excavation no&.required): If SAS not.located, eXplain;why t5ins-•11110 Title.50fficial Inspection Fount Subsurface-Sewage Disposal Syslem;•Page 12 of 17 Commonwealth of'`M_, sachusett6:T* F Title 5 Official Irnspecti n Form Subsurface Sewage,DisposM,.System Form;-Nof:for Voluntary Assessments: 116 V1LestWind.Circle Property Address: Stanton and:Marcia Abralarnson; Owner Owner's Name infgrmaton�is. required for every O,sterVille' MA, A2655 .April 1;8, 2012 page: CltylTown State'. Zlp Code, Date of.lnspecton D. System Information {cost ) ;Type - ® lea fi, its number gp leach:i`n;g chambers: numhee, - eaching galleries number. ❑ leach;iiig.trenehes number',.length- leacii'ing fields, number,.dimensions: El overflow cesspool number innovativelalternative system Type/name of technology:, Comments (note contlition of sod; signs of hydraulic failure, level of'ponding;"darnpsoil, condition of. vegetation; etc.): Soilsaboveleaching;:it appear unsaturated..No evidence ofsurface:ponding,breakout, lush -vegetation,or other evidence of hydraulic fail ure;,wassobserved:An observation hole=was dug into leaching pit atone and no effluent..contact staining was observed ri the stone or overlying soils Ad standing effluent,was observed to a depth;of 3 feet,below the top of:theleach pit: Cesspools(cesspool musfbe,pumped as part of inspectiori) (locate'o'n site plan); Nuniber.and configuration Depth:-top ofi'I quid to inlet`nvert, Depth:of solids layer Depthi o,=scum layer *ensions of:cesspool,. Matedals,of construction Indication ofgroundwater inflow ❑ "Yes, ❑ No t5ms t1t1,10• Tute 5 Official Iris"pedion ForkSOWif666 sewage Disposal System Pago 13'of:1:7` Commonwealth of Massachusetts _ Title S Offc:ia Inspect ®n {I=+�rrl Subsurface S.ewage'Di__ 61,:$y stem,Form-..Not-for Voluntary Assessments h 116,WestWind Circle• Property Address, Stanton and Marcia.Abrahamson - - Owner Owner's Name requ iredfor every information is, Osteruille MA 02655 April'IA, 201'2 ' page. City/Town State., Zlp Code Date of Inspection D. System Information (cont.) Comments (note condition of soil,.signs of,hydraulicrfailure, level of ponding,.condition of vegetation, etc.): Privy (locate on site plan). Materials of construction; Dimensions Depth of solids Comments (note condition of soil,,signs of`hy-rap is failure, level of"ponding, condition of vegetation, etc.): l5ins•11110 T'He 5 Ofriclal Inspection Form:;Subsurfacp'Sewage Disposal$y'.stem'•Page 14 of 17 Commonwealth of Massachusetts' - Q Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name Osterville MA 02655 April 18,2012 information Is required for every M� page. Cityfrown Slate Zip Cade Date of Inspection D. System Information (cant.) 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 ICO feet. Locate where public water supply enters the building.Check one of the boxes below: _ ® hand-sketch in the area below ❑ drawing attached separately LE lac K �c�c 1 . -rl tir NJ 0 V E tiin5•i 1r10. - TIVe 5 official'Iospe W6 Form;Subsurface Sewage Disposal System•Page 75 0!17" Commonwealth of Massachusetts Title 5 Official Inspection F®rm Subsurface Sewage Disposal.Syste.m Form.-N.ot:for Voluntary Assessments 116 West Wlnd'Circle' Property Address Stanton'and Marcia Abrahamson Owner Owner's Name !information is required for every Osterville. MA: 0265'S April 18 ,2.012 page. City/Town State Zip Code_: Date of Inspection D. System Information, (cont.) Site:Exam:: `Check Slope ❑ Surface water ❑ Check.cellar ❑ Shallow wells Estimated.de 20*pth to,high,ground feet Please indicate all methods used to determine Ihe high:ground water elevation:_ Obtained from system design plans�on record If,checked, date,of design,plan reviewed: ti/1.9184:_ 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 USES database-explain: Barnstable GIS Department.records You must describe how you established,the high-ground water elevation: Approved design plan on file with the Board of Health shows bottom ofsystem to be 4 feet,above the bottom.."of.a.'test pit in,which no gro;undwaterwas'observed. Town of B.arnstable GIS Department records indicate,that,the.property is;.ove�20 feet above groundwater,table: Before filing:this,Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110' Title 5 Official Inspection Form:Subsurface Sewage Disposal SyS1am•Pago 16 of 17 Commonwealth of'.Massachusetts Title sffl1cia! Iin pe�$ion Form 'Subsurface,Sewage D,isposal;Sysfem F,orrn Not' Voluntary Assessmen#s :. n.. `- ' 116,West;Wind Circle Praperty Address Stanton,and Marcia Abrahamson Owner; Owner's Name - Information is required for every Osterville MA' 02655; Apnl 18, 2012 pager Ctty(Town - State; Zlp Code Date of ins pe lion ' E Report Completelness Checklist ® lnspection Summary A H C, D, or E;;checked` ® Inspection Summary D{System Failure Crttena Appllcabl- All Systems}completed ® System.Information, -Estlrnated depth to hlgfi groundwater- ® Sketch of.Sewage DlsposaLS`ystem.ether dfiawn on,page 15 or attached In separate file, 15ms.•1 V,10 Tdle 5 Official Inspection Form Subsurfaca'Sewage Disposal System. Page 17;b61.7, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 Aril 16, 2010 every page. City/Town State Zip Code Date,of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: U only the tab key to move your David D. Coughanowr ` cursor-do not Name of Inspector use the return i key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 fe°0f1 City/Town State Zip Code 508 364 0894 1328 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: ` ® Passes ❑, Conditionally Passes ❑ Fails ❑ Needs Further'Evaluation by the Local Approving Authority oZ7�""k ��Y►+"ti---+ '`�° April 16, 2010 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys m•Page 1 of 17 li4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of grinder is recommended. 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 3 Compliance indicating that the tank is less than 20 years old is'available:. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. City/Townp 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 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 Y2 day flow t5ins•09/08 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 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. City/Town 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. ❑ ® 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 1.00 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a - no plan t5ins•09/08 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 ,M 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is P required for Osterville MA 02655 April 16, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage 526 gpd 9 ( Y 9 (gpd)): Detail: 2008-2009 Sump pump? ❑ Yes ® No Last date of occupancy: 3 days ago 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? El Yes ❑ No Water meter readings, if available: t5ins•69/08 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G1,p ,•''r 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. City/Town 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: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) • Approximate age of all components, date installed (if known)and source of information: Age: 23+years. Certificate of compliance issued 5/16/1986 (Board of Health permit#84-526) Were sewage odors detected when arriving at the site? ❑ Yes ❑ No r 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: feet Comments(on condition of joints,venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: . r ® 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: 8.5ftx6ftx5ft(1000gallon) ,4 Sludge depth: 2 in t5ins•09/08 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 M 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. City/Town 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 in Scum thickness trace Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? probe to top of tank Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Inlet cover under deck and not accessible for inspection. 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 t5ins•09/08 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 M 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16; 2010 every page. City/Town 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.):, F i 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): Y 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 Y Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,•''r 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. City/Town 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 at 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 appears level with no evidence of leakage in or out. Some solids in sump. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 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 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed.An observation hole was dug into leaching pit stone and no standing effluent or effluent contact staining was observed in the stone or overlying soils. 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•09/08 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 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16 2010 Cit /Town State Zip Code Date of Inspection every page. Y P P 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•09/08 Title 5 Official Inspection Forth: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 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is Osterville MA 02655 Aril 16, 2010 required for P every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: f ❑ 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: Town of Barnstable GIS Department records ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is 20 feet above groundwater table. s Before filing this Inspection'Report, please see Report Completeness Checklist on next page. a , t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 every page. City/Town 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 E� 3� Cy t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments °M 116 West Wind Circle Property Address Stanton and Marcia Abrahamson Owner Owner's Name information is required for Osterville MA 02655 April 16, 2010 f every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 {of,• � ��V�J-,I�. �- -� VT�,;LAC.rS �T eF U i,`l G A"S£SSOIi &Lox 1NSTAtLP.R'3 NAME&PkONE N0. „ 'mac TANca��czTx /00 o Q a.I �. .�., �LE�c OAlci rr7c t$ �.. a .a.., ms > UILDBR OR;.o � l�BR111dITt A'TE: .60MPUMCE i A'x'?. �S�epw�atiopi<91sBon�c BeEwee�.t�o; i Maximum ijust cl:Cn�aflii wi tteAhbletbi 'Bottarnomeachingpocility .. .,,_.,...,:..,Feet 'Pity c,�Vdt r Sug�►ty V1�:i1 nib a 9'.4011ActUty Of1my Was C7d3E as e�tcs ac within 7AA foot of leac[uo�feility) k?cl i cyt;'6Uetlaa p t X.eaclnin ec 1(ey{LFuny.vueEW4 sxisE vitl�it�3Qp frAt;of leaciiit:s�' il�tyVow rti Ck Z I r ' O I p a � y r�3 - 1- �a'6 •, �-�- s76•• A• a- a� ' 6 1a- 39' -,3 34 93. �a �9 L 0 C �rT ON�P SEWAGE PERMIT NO. '11LLAGE f INSTALLER'S N ME i ADDRESS S' fye pB UILDER OR OWNER �9 eo oa. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 4 oc 3 � 3'1 �y - � 1 No..-... y SLR s ,. Fss.. ��................ j Zs1 COMMONWEALTH OF MASSACHUSETTe"" { ` ,tr�° lly�a OAR® OE HEA T ......OF.... .. .. ... . . . ....... �- Appliration for Disputia1 Morkii Tonstru.rtiun ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at, ,&, e a /p,� Coca' n-Address ,N 1!e jl r fit}No. ......... lj' + -eJ-•-- �Z l �:Ls`��eLIL'y�� ..... Owner Address Installer Address y Type of Building Size Lod -lJ.....Sq. feet Dwelling—No. of Bedrooms---------- .._. _....................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons Showers — Cafeteria dOther fixtur . --•-------------••--•........-•--••......--- ----------...----•-......------ W Design Flow.............. ....................gallons per person per AAaay Total dail �{iow__.._..._. ___j..�_.._._.___._.__.gal�lonsy� WSeptic Tank—Liquid capacity./ gallons Length-__.IQ._gc__ Width._ Diameter................ Depth____3.. x Disposal Trench—No..................... Width......... Total Length.............. Total leaching area....................sq. ft. Seepage Pit No........../--------- Diameter........6-------- Depth below inlet...... Total leaching area.419__._�7.sq. ft. Z Other Distribution box (4-Y Dosing t nk `" Percolation Test Results Performed by._._W PC- ... 1 �C,Nl_/4&&l...... Date.....-_..del__- `�_- ---�i'. W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._ _ ____ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ _ - O Description of Soil rY1 PT. � ,/` ..._ X_._... ..... ..J� x V .....•--••-•---•-----------•------•-•----•..........•..................................•-••-•-------•----•--•---••-•••---------------------•--•-----------------•••-••-•------------••--•--•-•----------- W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••--•-•--•--------•--- U Nature 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 iITIE 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 ued by the board of h lth. Signed------ -•• ----------- -- - --- - � D Application Approved By.........__J4� r... _.. 6�� 5 Date Application Disapproved for the following reasons:................................................................................................................ .......-•-•---------•------------------------------------------------•--•---•---------------•--------•--.•------------------•-------•--•------•-•-----------•------------•--•--...........-•-•---------- Date PermitNo......................................................... Issued....................................................... Date ��-- -- ----L. -,- _-_------ ----------------------------------------------- --- --- --�I 4 t Y ti� J I No................--.....-- COMMONWEALTH� �OF�ASSACHUSETTS! � /'° Of EA T Pr - T oF... .. �. �.. Appliration for Uhip o al Works Tomitrnrtion ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst at .. --. ....... - ._.....- ..-- .� .. - .... .... Loc 'on-Address JW�° �eST_ + 0. �Owwnyer"' r f + Address W ! // �......................e" ---------------• p'e—&f l____('"' _-.c 7=__f_.[__'Lc'L..°.K.t.'', .�/V,a^:•:4c ........ Installer � Address /�- ��--`` UType of Building `� Size Loth(2..Z i.......Sq. feet 1-1 Dwelling—No. of Bedrooms---------- -- ---------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building l persons a g �-I�---- No. of P (�---------------- Showers ) — Cafeteria ( ) Otherfi r -•-•---------------•----.......-•------•-••---------•••......---•---- W Design Flow............. .....................gallons per person peridayr Total dail ,,flow__-_-___.__ ._ ...............__...............ga�,lonst p q p yl g g /_•..�-x__ Width-- ----------- Diameter________-___-- Depth..W Septic Tank—Liquid uid ca acit allons Length _� ll p - _-- x Disposal Trench—No..................... Width.........f--------.. Total Length.........:...p_r._. Total leaching a rea....................sq. ft. Seepage Pit No..........I--------- Diameter........ .._...... Depth below inlet...,. _.......... Total leaching area.U_�,�...sq. ft. Z Other Distribution box C'I<"1 Dosing tank1-4 ( ) a Percolation Test Results Performed by.....?Civ I/l1,61______ Date........ Test Pit No. 1................minutes per inch Depth of Test Pit:................... Depth to ground water... LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water/ �.l�° T I�� O Description of Soil...... .lJ .... i� l�„ _.__ -- - - - ------------................................................. VW ---------------------------------------•••••••-•-•-•-••-•-------••-------------...--•-••--•-•-......---•-----•-------------...... - -------- Nature 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 TITL' 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 of h lth Signed....✓ ... •--•••......-•---•-:....-- �j D e Application Approved By..._... ✓" +" ..............- Date Application Disapproved for the following reasons-------------------------------------•-------•--------------------------------------------•-••-•-•-----•......._ ..............••-------------••-----------------•--•---------....--------...----------------•--------•---•••---•---- ..................................................................--------------- ;,:Date PermitNo......................................................... Issued..............................I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, , el .....OF....... ,c "e ........ s., (9rdif irate of Tontplianre THIS IS TO CERTIFY, Tha t e Individu i Sewage.D sposal System constructed ZT""1 or Repaired ( ) b � .._ - !e Installer at..Z -•- ....�ll �� �. L ....---... { has been installed in accordance with the provisions of TITL 5 of T e State Sanitary Code as described in the application for Disposal Works Construction Permit No..__.� f-. ___________ 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 t. BOARD OF. HEALTH �� ..... No........... �.. ..... FEE:_- .�!. ..... i- .. Permission ><s hereby granted.. � �.- 4 a��;!�` •--�'"'------ f�---------• "�----.....-•-----...._:.................. � . to Construct (• or�Repair ( ) an Indiv•dual Sewage, isposal System - --• Street as shown on the application for Disposal Works Construction Permit No. .... Dated......:..................................: u: ------- ..._ ealth ' DATE.......................................�,. ..: ...... FORM 1255 A. M. SULKIN, INC., BOSTON x GE"cc A IQOTEs ELE�/•=d?f5 �L.E.\/• ! _� �J--AI.-L e1—CV.. S"oujO AFC P E T,`/ 1 Ito o c?" USG C^ ES. E3A, -)*.'A 2 PI-k:14 ALL L.IWF-5 A MrurMu of t F l)wll.>FS`> C�THE��tsE �F` Ga�IE iD. ALAittE Sti JTE� SMA.IJ- j \ --- eke CAST ALL. SEPT< TAl.3L5 �I-•1-E eSJTio,J $p1e, A#,J0 s L.!_A,CN4"6, P StlaLL f_c!:= -1•h' ! .,• --- - - _ SO-- tiz�r�to✓E Ate Sr a. 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