HomeMy WebLinkAbout0205 WEST WIND CIRCLE - Health 205 WEST WIND CIRCLE, OSTERVILLE
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RECEIVE®AP P 2 2 2000
TOWN OF BARNSTABLE
COMMONWEALTH OF MASACHUSETTS HEALTH DEPT.
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI 3 DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner DARBY MCQUILLAN
Address of Owner: 205 WEST WIND CIRCLE OSTERVILLE,MA 02655
Date of Inspection: 9/11/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CA,1R 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and thatthe information below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes ft EO
_ Conditionally Passes t�
_ Needs Further Evaluatio By the Local Approving Authority S E P 2 2 2000
_ Fails r"'
TDiNIN 0E BAR 4STABLE
WALT,4 DEPT.,
Inspector's Signature: �) �4 Date 9119I00
The System Inspector shall su mit a copy.of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer;if applicable,and the approving authority. -
a
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system.is performing at the time of inspection:M,
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER _
MAINTENANCE.RECOM MEND MOVING SRPINKLER LINE OVER SEPTIC TANK COVER. -
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revised 9/2/98 Paae 1 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9111/00
INSPECTION SUMMARY: Check A, B, C,.or D:
A. SYSTEM PASSES:
X I have not found any information-which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
9
B. SYSTEM CONDITIONALLY PASSES: .. 4
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure
is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved
by the Board of Health.
n1a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
n1a The system required pumping more than four 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
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revised 9/2/98 Paoe 2,of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9/11/00 ,
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 the public health,
safety and the environment. +
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I:
.NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well.
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The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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,Method used to determine distance n/a (approximation not valid).
3) OTHER
n/a
F1:
. C
revised 9/2/98 Paoe 3 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,CERTIFICATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011'L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9/11/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No':to each of the following:
I have determined that one or more of.the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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 of 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 1/2 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 n[a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 1 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for colifoinm bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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: .
The system serves a facility with a.design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
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 11 of a public water supply
well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of
the Department for further information.
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revised 9/2/98 Pape 4 of 11 '-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
.. CHECKLIST
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner: DARBY MCQUILLAN
Date of Inspection: 9/11/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No w .
X _ Pumping information was provided by the owner,occupant,or Board of Health. '
4
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X _ As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
y
X The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1.5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal
Systems.
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revised 9/2/98 Paoe 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040 `
Name of Owner DARBY MCQUILLAN
Date of Inspection: ° 9/11/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):n/a
Total DESIGN Flow: 330 gpd
Number of current residents: 2
Garbage grinder(yes or no): NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no), ,
Seasonal use(yes or no): NO ,
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a ,
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a ;
Design flow: n/a gpd(Based on 15.203) ,
Basis of design flow:n/a
Grease trap present:(yes or no): NO
!Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no): NO
Water meter readings.if available: n/a
Last date of occupancy:n/a °
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no): NO
If yes,volume pumped n/a;.gallons
Reason for pumping: n/a I;
i
TYPE OF SYSTEM
t
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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1984
Sewage odors detected when arriving at the site: (yes or no): NO
.pet• _ - • -
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
revised 9/2/98 `Ie Page 6 of 11
f,
PART C
SYSTEM INFORMATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P0111040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9111/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 14"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER ,
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: nla
Dimensions: 1000G L 8'6"H 6'7"W 4'10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee.or baffle: 33"
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: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL 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 r
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.) oh
L _
nla
tl:
revised 9/2198 Paae 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9/11/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
a
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: NO
Alarm level: N/A Alarm in working order: NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X _
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,'evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
i,
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments: i
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a r.
revised 9/2/98 Pape 8 of 11° - ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9/11100
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(1) 1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a `
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (nla)n/a
leaching fields,number,dimensions: (nla)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2'OF WATER IN IT AT THE TIME
OF THE INSPECTION.THE SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: _
(locate on site plan) ;
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: nla
Depth of scum layer, n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)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: nla
Depth of solids: n/a t `
t
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
n/a
revised 9/2198 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011.L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9111/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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revised 912/98 Paoe 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 205 WEST WIND CIRCLE OSTERVILLE, MA 02655 M121 P011 L040
Name of Owner DARBY MCQUILLAN
Date of Inspection: 9/11/00
} A .
NRCS Report name: n/a °
Soil Type: n/a ;
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater.Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
r
Checked with local Board of health
Checked FEMA Maps `
Checked pumping records
4,
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
revised 9/2/98 Paae 11 of 11
c
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
Jolui
One winter Street Boston,Ma. 02108
` D.E.P. Titlee V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508) 564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION �s
Sn a� L�- ow aL-1 b F®
Property Address: 205 Wes ind Circle Osterville Address of Owner: 2
Date of Inspection: 618198 (If different) *°' ?� •4
9
Name of Inspector: John Graci McQuillan , �9
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) 1 �°
Company Name,Address and Telephone Number:
# �y
6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes t
This Inspection Is based on criteria defined In Title V
_ Conditional) Passes code 310 CMR 16.303.My findings are of howthe system is
y performing at the time of the inspection.My inspection does
_ Needs Further Evaluation By the Local Approving Authority not Imply any vrerrantyor guarantee ofthe longevity ofthe
F lls septic system and any of Its components useful life.
Inspector's Slgnature: 1 Date: 61sf98
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria .
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired..The system, upon completion
of the replacement or repair,passes inspection.,
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection,or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised WNW) a
One Winter Street • Boston,Massachusetts 02108.• FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 205 Westvvind Circle osterville
Owner: McQuillan
Date of Inspection:619198
_ Sew.acie backup or.breakout or high.static water level obser.ved.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if.
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four 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
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 the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF'HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an 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
` cesspool.
SAS is in hydraulic failure.
(revlaed 04r17)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 205 Westwind Circle Osterville
Owner: McQuillan
Date of Inspection:618198
D]SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and.the environment because one or more of the following conditions exist:
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
a
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
;t
{reylsed 04127)87)
f. •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B p
CHECLIST
Property Add re s s: 205 Westwind Circle Osterville
Owner: McQuillan
Date of Inspection:618/9s
Check if the following have been done:You must indicate either"Yes",or"No"as to each of the,following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A. "
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow. '
_c_ — The site was inspected for signs of breakout:
x — All system components, excluding the Soil Absorption System, have been located on the site. i
x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected•
for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from,owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H. `
Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
x
— — unacceptable)[15.302(3)(b)]
• •
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 205 Westwind Circle Osterville
Owner: McQuillan
Date of Inspection:619198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ago g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
Sump Pump(yes or no): No
Last date of occupancy: nla '
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No' a
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: nra
Last date of occupancy: nra
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:n gallons
Reason for pumping: nla
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
1986
Sewage odors detected when arriving at the site: (yes or no) No
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 205 Westwind Circle Osterville
Owner: McQuillan
Date of Inspection:619198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 8"
Material of construction:x concreate_metal_FRP_Polyethylene—other(explain)
If tank is metal, list age nos . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le'e"rlev^w4'10"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:S" r
Distance form bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: measured
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and all components are structurally sound and functloning property.Recommend pumping everytwo years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rya
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rya
Scum thickness:rya
Distance from top of scum to top of outlet tee or baffle:rya
Distance from bottom of scum to bottom of outlet tee or baffle: ria
Date of last pumpingn't-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1'2-,
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?o'^rrr
Diameter: 4"
gaimments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 205 Westvrind Circle Osterville
Owner: McQuillan
Date of Inspection:6/9198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Na
Capacity: Na gallons
Design flow: Na gallons/day
Alarm level:_nra Alarm in working order?_Yes No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
We
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: pia
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_v..
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Na
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 205 Westwind Circle osterville
Owner: McQuillan
Date of Inspection:6ierg8 ,
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) .
If not determined to be present,explain:
rda
Type:
leaching pits,number: one 1000 gallon leach pit
leaching chambers,number:roa
leaching galleries, number: rda
leaching trenches, number,length: nia
leaching fields,number,dimensions:nla
overflow cesspool,number:nla
Alternate system: rda Name of Technology:_nla
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all components are structurally sound and functioning properly.System never had more than t 112'of water in it
CESSPOOLS: '
(locate on site plan)
Number and configuration: rda
Depth-top of liquid to inlet invert: nia
Depth of solids layer: rda
Depth of scum layer: rJa
Dimensions of cesspool: rda
Materials of construction: nla
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rJa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rya
PRIVY:_
(locate on site plan)
Materials of construction: rda Dimensions: rda
Depth of solids: n/a
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
(revised 044r27)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
205 Westvvind Circle Osterville
McQuillan
618198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
I
h• L-AEc)]
1
v t
� t
(revised04127197) Papa t of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
205 Westwlnd Circle Ostervllle
McQuillan
618198
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
_X— Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
r `
(revised 0427197) of 10
t
ale r-- � ✓
LOC TIONO SEWAGE PERMIT NO.
L.,o 41r"�llaldcll�-le i
VILLAGE
INSTA LLER'S NAM i ADDRESS
e U I L D E R OR OWNER
dm,r/a
„ DATE PERMIT ISSUED
-
DATE COMPLIANCE ISSUED =.-
4
Oq()Ai
.,j
i
� �� � Fps. .S'd
No....... .. ...... ...... ...........
b ' COMMONWEALTH OF MASSACHUSETTS r
BOARD OF H E A TH
Con BOARD
F.... .............
Appliratinn for Uispusa1 Vorks T niltrnrfirrn Vanfit
Application is hereby made for a Permit to Construct HI-) or Repair ( ) an Individual Sewage Disposal
System at:
Locati n•A rress / �j Lott No.
�
......: _ l=' _.�.�i..... f!I �J p.l. _...L AA
....................
... ntA!f��.'L/l._. ......................
Ow
Installer Address Q'-
U Type of Building Size Lot.___fjV.`.4'Sq. feet
Dwelling—No. of Bedrooms . . P.Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T
ype of Buildin g :�1riT.._ __. No. of ersons.........6............... Showers (� — Cafeteria ( )
04 Other fixtur ----------- --------------------•-•----••-------------•---------------------•------- ------- - ----------
W Design Flow.......... ---------------------gallons per person peI d�y� Total dailiow______---. . ...............gallPns.�,J
WSeptic Tank—Liquid capacity./ allons Length..,�_.� Width.....}",...__ Diameter________________ Depth...�j.. _.
x Disposal Trench—No..................... Width.................... Total Ee-ngth............ Total leaching area....................sq. ft.
�. Seepage Pit No........ .......... Diameter _.__ . Depth below inlet....... ._.. . Total leaching area..
� � � ---- P � ----- g y�---rJ--.sq. ft.
Z Other Distribution box ( 1) Dosing tank ( )a Percolation Test Results Performed by------- Date......1 n�1¢./
a Test Pit No. I................minutes per inch Depth of Test Pit._.._... ..__.I_I.- Depth to ground water-.-.�.{,-r_Y,,
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit__� ...... Depth to ground water........................
-1�
P4 .................................................. L / y^�
Description of Soil .ri��11 -W----..... !v - -- -- -
x
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 gads&, D the boar't�/�lt��. '4�-�..........................
f d Date
ApplicationApproved By................................... s__.-.----------•-----_-------.-- ................. ---------
Date
Application Disapproved for the following reasons:... .......................•....__............................_.._._.........._......_........._............
-•------------------------------------------------------------------•------------------------•-------------.._..------...-••---•--•--•-•---••-•---•----•-•-•-------••--•••---••----------------.........
Date
PermitNo......................................................... Issued........................................................
Date
No................--....... ..........................
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA"T
..........
41'.A.r. 0F... -........... . ..................
Apptiratinn for Disposal Works Tonslrnxtiun ramit
Application is hereby made for a Permit to Construct { ) or Repair ( ) an Individual Sewage Disposal
System at: 1�
......�, ' " ....IAA: I A{17 --.4 t.Z.C.;= ...._ t` ..........a.... .L �1/ _, =l E---
LocatTn A ress Lot No
....---f:7......�c.E !- f �... '- ------- -------- n.zlfz?? > n........................
Adddr�s��r. � .
---.......-•--- ... . --. �..w .2- 11..R.I.L).Z:f ---- --------_- MR ............................
Installer Address
U Type of Building Size Lot-2.01LI ._Sq. feet
I—I Dwelling—No. of Bedrooms............
-------------------Expansion Attic ( ) Garbage Grinder ( )
pal Other—Type of Building + ___ __ ._ _ No. of persons........ _.. Showers � ( )
a ---•---------- ) — Cafeteria
Other fixtures .•••-•-•------••---•---••-•• ----•--•-------------•.....
Design Flow___......____.,;----------------------gallons per person par . Total dail ,flow----------_3 ....................p1 s�
J
W '
WSeptic Tank—Liquid capacity gallons Length_ ._.. ..... Width.._.,__._ Diameter................ De th..__..
x Disposal Trench—No..................... Width...-_y------------- Total Length............... Total,leaching area....................sq. ft.
Seepage Pit No--------I---------- Diameter........6......... Depth below inlet............... Total leaching area._R..7..sq. ft.
z Other Distribution box (? ) Dosing tank ) rr
'"' Percolation Test Results Performed by.._... ..,.......%._: /C, �. l t✓ Date.....f2.._`. ......:��.
Test Pit No. I................minutes per inch Depth of Test Pit_..._ ...._/.L_. Depth to ground water 44 Test Pit No. 2................minutes per inch Depth of Test Pit._ .. ------- Depth to ground water___.....................
P4 --------- ......................................... ......
Descriptionof Soil � �__,. !.. ..A. . -•---••---•--•-----------------••-----•----•••--------•-•-••---------...._----•---•--
x
W
-------------------------------------------------------------------------------------------------------------------------------------------------------------------••----------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
...........................-•---------------------------------------•---- -•--------........-•----••----------------------------------------...--------•--------------------------------••--•--•---•-•--
ftreement:
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 'slued by the board of i�alth.
- � -Signed---f�-•-•--.._._ �-� -c--�-
- Date
ApplicationApproved By-----••--•-•--•-••--•-----•------. -. ......................................................
Date
Application Disapproved for the following reasons---------------•----------------------------------------•---=------. .....................................
--------•••.....-••-------------------•-...-----•-------•---•--------------•--•-------••••••-•------•••-----------._......•-•----------•----------------••-----------••--•-•-•---••--•-•--•---..._......
Date
PermitNo......................................................... Issued........................................................
Date
e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..,(...t ? �. `�.....-...OF....:� .. , ' 7. .........L .. :.. ." .........
�r�i�ixtt#r of f�unt�rlittnrr
THIS I TO CERTIFY, t the I dividual Sewage Disposal System constructed (�-) or Repaired ( )
by.............`' y�]�- ..... �Y�J 2 <d .......................................------- -----.............
9 I/ Installer / �J -�^�
at itr j rJ__j.........
�! _.. ] r� ?. -- �'G j +7 1
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL N�FU CTION ATISFACTORY. -,--yr�
DATE................�. .....-------•--........... Inspector................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
o .., -` 4. ....,OF...... ?... ,r' �< Ems -L.-` r
No....'9.Yn.
�, ......... .. .... FEE........................
Disposal Works To-n—oftudion frrutit
Permission 's hereby granted �_ '�3- .✓L -----._ ..... - 1w,2.
to Construct ( ) or\Re air ( ) an Individual Sewage Disposal. System 7
at No.
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... r
..
DATE........................... l!-. �'-••-•--------•-•--........ Board of Health
FORM 1255 A. M. SULKIN, INC.. BOSTON
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