HomeMy WebLinkAbout0242 WIANNO AVENUE - Health 242 Wianno Avenue, Osterville
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LOCATION ' LIAAA0 AV C_ SEWAGE #
VILLAGE O S�"e.rVtllt, ASSESSOR'S MAP & LOT NO �YS
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY SW
LEACHING FACILITY: (type) (' 0+TS (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac 'ng facility 1 Feet
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Furnished by T►/►s t� J FD/C
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
o d� Al
- .-OF...,- r $rast��*( n
Appliration for 11hipaii al orkii r tit
c�Application is hereby made for a Permit to Construct ()Q) or Repair idualwagesposal
System a
0112
n/d�rs .8.1VH.1.SZz6_,gG t No......�l t
---..r.� .S All S.Lo 1 � 7
Owner Address
------------------------------------------- ----------- ----........------------------------------.
Installer Address
Q Type of Building ee ,i Size Lot..St.�Q ....... feet
U Dwelling—No. of Bedrooms.........._-!................... .....Expansion Attic (tqD) Garbage Grinder 6)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
Q ---
W Design Flow..........6D...........:...............gallons per person per day. Total daily iow____.__..__...........__....................gallons.��
r_
W Septic Tank—Liquid capacitylb— W_gallons Length.AW.�____ Width.__;___ $. ... Diameter__- ------ Depth...57....._
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit Nei--------Z------------- Diameter.._..ifs--------- Depth below inlet.3+..d�._........ Total leaching area..'376.....sq. ft.
Z Other Distribution box Dosing nk ( .6) _
Percolation Test Results Performed by._.._... A�K' ... .. '��
W ...................... Date ......................................
Test Pit No. 1...A2-____minutes per inch Depth of Test Pit____ �.......... Depth to ground water.
f=, Test Pit No. 2._G ......minutes per inch Depth of Test Pit----V3........... Depth to ground water._ 5. -�► v�
W ------•----- ....-----—............... ..............
-------------------
•-----------------.--•---•-----------------
.... -•--------------....
O Description of Soil-- .1 _f-sS�.'...�-o�`"'` �ftl_.-J6--��'i3. .Y�/l��_- �1�1.��
-------------
V ....•-•••.....................•-•-N... _......_.--- ._..--L®flrM ea�j`sOtC. t ` l�li7
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 f the State Environmenta ode— undersigned further agre of to , ce,the
syste n era i nt an a een u by t board of health. y
01
.�
Signed�- ----
�y
Application Approved By -�';. II�Lt'>...._ .......... . .. .... /(�y"f/" ---------------------------------- ---.-L-.."'......��..
<<�'i���s�V Date
Application Disapproved for the following reasons: .............. ......................................... ................... ...................
Permit No. .....�./.........7�-..�------------------- Issued -------------z11-- -- rare----------------
Dace
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
.. e� .t:a.l---------------- OF � ► R. - -.4' C� --------------------------------....
Gel~#tftra e of C antyliance
THIS IS TO CERTIFXThat the Individual Sewage Disposal System constructed ( X ) or Repaired ( )
by -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
,�5-ea'CaC
Installer
has been installed in accordance with the provisions of TITLE of The State E vironmental Ce as describe iry
the application for Disposal Works Construction Permit No. .- � ...� - -.---. dated ------ ----:'�' ®'.7.( ;
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO ED AS A GU AhVEE THAT THE
SYSTEM WILL FUNCTI ATI! ACTORY.
DATE............. .................... 9-- .... .�.----...................---.. Inspector - - ----- .........--- ------------= -- ---
No................-...... FEs..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Bispoii al Works Tonutrurtiort rrnnit
Application is hereby made for a Permit to Construct (A) or Repair ( ) an. Individual Sewage Disposal
System at�
_..........�... .......................................... ...................--. . ----.....---- .....------------------................---
Location-Address or Lot No.
•....................._........................................----••..........._................ ..........-----.......----.........---.....................-•-•--.................................
Owner Address
W
Installer Address
Q Type of Building l Size Lot__� '�`-�'�'t.......Sq. feet
Dwelling—No. of Bedrooms..........................................Expansion Attic (A�I a) Garbage Grinder (4t, )
Other—T e of Building No. of persons............................ Showers — Cafeteria
QI Other fixtures ............................
W Design Flow..........5D..............................gallons per person per day. Total daily �ow......... ...................._....gallons.
WSeptic Tank—Liquid capacity_ " gallons Length..'t ..` ... Width_,:-.---.--- Diameter.._ ........ Depth...`._
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....µ............sq. ft.
Seepage Pit No...... ........... Diameter------k_` --------- Depth below inlet-. .............. Total leaching area....L .....sq. ft.
Z Other Distribution box ( 4E):) Dosing,tank
14 Percolation Test Results_ Performed by.......!'415 : !_�.-`��'..�'A_11 _. ......_... Date__.....................................
Test Pit No. 1... __. __._.minutes per inch Depth of Test Pit.__._!�.......... Depth to ground water_.= . ..!�.....
Test Pit No. 2-. `^-:_....minutes per inch Depth of Test Pit..._a.�........... Depth to ground water-. �' +.. '!f
Q+' ---•---- -- -------•------• •. -• . t- ---------------------------•..----
Description of Soil-- ' `` l~
�. ....AatU I
�vG`.........n ... ��...
W •----------•---------••------------------------•-•-------•---................._.....-----------•-•-•---••-•-••-•---•---•----•---------•----•-----•••------------•--••----......._......................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................I...............................................................................................................................................
Agreement: 0
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5,.of the State Environmental Code—The undersigned further agre s of to c e
system i'n erat'ory nti�l.a', " ' of-CZi pliance has been issued by the board of health. �Gt
% Signed ---------------------------------------------------........................................................ ------ i
to
Application Approved By ------ ............ ....................................................... ... .. .. ................................... ... .
................Dare---....--------'
Application Disapproved for the following reasons- ........................................................--------------------------------------------------------------- ---- --------
................................................................................................................................................................................................................ ----------------------------------------
Date
PermitNo. ................................................................... Issued -------------------------------------------------------------------
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... OF .
. �._I�.�....�-6 Vic......................... ........ ......
Certifi ate of 01-larayliatue
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 9, or Repaired ( )
by .... ... . .... ........ ---- --. ..-- .. --- --------------- .....------------. --------
Installer y
re
ti '� °�, .. ". --- b ........... .
at ............................................................... : ..
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...................................... ...... dated --....----.--...---................--------.----
THE ISSUANCE OF THIP CE TIFICATE SHALL NOT BE CONSTRU S G'MARANTEE THAT THE
SYSTEM WILL FUNCTI N S S TORY.
DATE......:............................. ..-- -- --- --- --....----- Inspector .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .`)'...`....P`....................O F..... k t._ ti .............................
No......................... FEE........................
Diaposal Vorkii 0-0onofr ion rrmi#
Permissionis hereby granted..............................................................................................................................................
to Construct ()�) or. Repair ( ) an Individual Sewage Disposal Syste}n
t.0 .t. ,
atNo...........................................................................................................at ?. 1
Street
as shown on the applicatio for Disipsal Works Construction r it No__ ted.._.._......_..........
..........
s
_ Boar of 'ealth
DATE.......................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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HIGH RISK CATEGORIES
The Public Health Division must comply with the Massachusetts Department of Public
Health Order for the administration of influenza vaccine and is requiring all participants
to complete a flu-risk assessment questionnaire prior to receiving a flu shot.
You must answer YES to one or more of the following questions to receive the flu
vaccine this year:
❑ Are you 75 years of age or older? YES NO
❑ Do you have Lung or Heart Disease? YES NO
❑ Do you have Asthma? YES NO
❑ Do you have a chronic metabolic disease: Kidney YES NO
Blood or Diabetes (treated with medication)?
❑ Do you have a weakened immune system? YES NO
❑ Are you pregnant (2"d or 3rd trimester)? YES NO
o Are you a healthcare worker over 50 years
and directly involved in patient care? YES NO
Signature of person to receive vaccine, or that person's guardian
X Date:
SULLIVAN ENGINEERING, INC .
December 15 2004
Thomas A. McKean,Health Director
Barnstable Health Department
200 Main Street
Hyannis,MA 02601
SUBJECT: 242 Wianno Avenue
Septic System Expansion
Dear Tom:
For your consideration, we are forwarding you information regarding a proposed
expansion at 242 Wianno Avenue, Osterville, MA. The property has been inspected by
James Ford, a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310
CMR 15.000). His findings indicate that the system passes and according to our analysis of
the system design, there is present capacity (708 gpd) to expand the number of bedrooms
from four(4) to six (6) per Section 15.301(5) System Inspection. The analysis also identified
that no garbage grinder was proposed in the past, nor for the future at this property. Our I
client wishes to make this expansion.
Sincerely,
Peter Sullivan,P.E.
CC.: Michel Mangalo
OF
PETER
Enc.: 1991 Design and Plan SllLL11iAS� '`-
Disposal Works Construction Permit i29
Official Title 5 Inspection Form
7 PARKER ROAD, OSTERVILLE, MA 02655
TEL: (508) 428-3344 PSSULLQAOL.COM FAX: (508) 428-3115
i
Sullivan Engineering, Inc.
7 Parker Road -P.O. Box 659
Osterville, MA 02655
Project: Michel Mangalo Mailing: Michel Mangalo
242 Wianno Ave. 242 Wianno Ave.
Osterville,MA 02655 Osterville,MA 02655
1978 Title 5 Code
Installed 1991 Plans Dated: 9/04/1991
Original Septic Design Analysis:
Residential Flow: Bedrooms
110 x 4 = 440 gat
Septic Tank Requiements:
440 1 x 150% = 660 gal
Used 1,500 gal Tank minimum
D-Box:
Leach Pits Provided: Quantity Size Capacity
Disposal Pit: 2 4'x6' 600 gal
Stone: 2'
Sidewall Area 220 SF x 2.5 550 gpd
Bottom Area 158 SF x 1 158 gpd
Total Provided: 708 gpd
Daily Flow: 440 gal
Garbage Grinder:
This analysis identified no garbage grinder was proposed in the past, nor proposed for future use.
Per Title 5, Section 15.301(5) upgrade of the system is not required if the system was designed to accept
design flows resulting from the change in use or expansion of use.
New Capacity 6 Bedrooms x 110 gal 660 gal
OF
SUL��AN
NO.29733
CIVIL
fVA �
12/14/2004
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 242 Wianno Avenue
Osterville, MA 02655
Owner's Name: Michel Mangalo
Owner's Address:
Date of Inspection: November 24, 2004
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 29, 2004
The system inspector shall subL a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
• time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Pagd 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 242 Wianno Avenue
Osterville. MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further.evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310.CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface:water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and.the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well"._Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
r
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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''/z 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 well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of.
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply.to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or 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.
4
Page 5 of'11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
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
P g P
✓ 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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 6 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 4
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2003-242,000 gals.; 2002-317,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous.inspection records,if any)
Innovative/Alternative technology. Attach a.copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed in 1991 -per owner
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan) -
Depth below grade: 28"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 12"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 8"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. The inlet
cover was 12"below grade. Recommend pumping.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
i 7
Page 8 of 'I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Manzalo
Date of Inspection: November 24, 2004
TIGHT or HOLDING TANK: None (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: eallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if,present must be opened)(locate on site plan)
Depth of liquid level above.outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no).
Comments(note condition of pump chamber.,condition of pumps and appurtenances,etc.):
8
I
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-4'x 6'(600 zal.) w/2'stone-per design plans '
leaching chambers,number:
leaching galleries,number: f
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.):
One pit(91)was under a shed. The pit had 1.S'oflLguid on the bottom. The scum line was 2'up from the bottom. There did not
appear to be any signs of failure. The other pit 02) had 2'ofliguid on the bottom. The scum line was at the same level. The
pit was under the driveway. There did not appear to be any signs offailure. A video camera was used to inspect the pits.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, AM
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
J
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10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, AM
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topozr
qphic and water-contours maps, the maps were showing approximately 20'+1-to ground water at this
site. Using the Cape Cod Commission technical bulletin, the high groundwater adjustment for this site(MIW 29, Zone A. 10104)
was 2.2'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no.warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
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THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD OF HEALTH
o' vu.f.Jl...............oF.! ���.. b}dA......._P
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Aphrutwu for Disposal Marks
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34 Other—Type of.Building No: of persons......_.------»»--------- Showers ( ) — Cafeteria ( }
dOther fixtures ...........................................................................................». .._»..»....»....».»... ».__.
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o� Sept .Tank—Liquid'capacity 15W.gallons Length.!t.......
..Width.......:b... Diameter. _.__Depth- ------
Disposal Trench—No. Width_........._....Total Length-...._.._.»._...Total leaching area_........_......_..sq.ft.
i Seepage Pit No...... ........... Diameter__.. ..._.... De h below inlet. +�.:..___Total leaching area... _35....sq. ft.
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64,
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U Nature of Repairs or Alterations—Answer when . . »...
applicable ____.--__. __.__________________-__-._-- - ___-__Y._.__-..-__�____.._� _.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TITLE ) f the State EnviA— undersigned further agre or to c e
syste n ra i nt Ea u by t board of health. -P
Signed _._.
dd
Application Approved By ......_.._._. ......_....._._........._.. .... _.. - .............._ .._. ......... �
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Application Disapproved for the following reasons: ........................_._....._.-........_.-....................................................................-•---•-
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Permit No. _... ....._71.. .f,�___._..._.... Issued ............. ..... 1�,r1_ �_.
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH -
.. avu..� of ._BtL .�►.S i�t A-6.........................................
(�er#ifittte of �nmpliunre
THIS ly TO CERTIF , That the Individual Sewage Disposal System constructed ( K ) or Repaired ( )
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has been installed in accordance with the provisions of TITLEAoj The State Egvirotimental a as a cribeicy
the application for Disposal Works Construction Permit No. .. l ��.,!<...... dated .,. '�. �'.l•.--//:•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COy&tRI� U�RED AS A GJ,�►gm THAT T,}it
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Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for Osterville MA 02655 04/07/13
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:When filling out A. General Information
forms on the
computer, use 1 Inspector: 1+
'
only the tab key
to move your Mike Hudson
cursor-do not Name of Inspector
use the return
key. Septic-wiz Environmental Services
Company Name
16 31 Midway Dr
Company Address
Centerville MA 02632
�fOA City/Town State Zip Code
508-367-5669 DEP SI#4254
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
04/19/13
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.
b&j ,-717)j
3
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
t
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M >•`'v 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. City/Town 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:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,° please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
jf� 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):
I
❑ 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:
I ❑ 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: C
i ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection Fora,
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. City/Town 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.
I
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution.box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•11/10 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
M 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is S. Dennis MA 02660 04/07/13
required for
every page. Cityrrown 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.
El ® 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.
❑ z Any portion of a cesspool or privy is within 50 feet of.a private water supply well.
❑ Z 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 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
r necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
r 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—1WPA) 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,
,ror 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. CityTTown 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): 6 Number of bedrooms(actual): 4
DESIGN.flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 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 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
contemporary
Number of current residents: 2
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
GPD
-301
Water meter readings, if available (last 2 years usage (gpd)): 2012011 - 01 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied for sale
Date
i - 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 El No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis' MA 02660 04/07/13
every page. CityrFown 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: Homeowner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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•1 MO Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate ace of all components, date installed (if known) and source of information:
22 years, installed 1991 via prior inspection
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 38
11
feet
Material of construction:
Y
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints ok, vented thru the roof, no leaks
Septic Tank(locate on site plan):
Depth below grade: 32"w/24" riserfeet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: e/A
ars
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions:
5'8"Wx10'6"Lx5'8"H - 1500 gallon
Sludge depth:
410" (2" thick)
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
.
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness 1/4" - minimal
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
18"
sludge probe, snake camera, tape,
How were dimensions determined? floodlight, mirror
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend pumping 1x every 36 months, inlet and outlet tees in good working condition, tank
structurally sound, liquid level even w/outlet, no evidence of leaks in or out of tank.
i
Ij`.A 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•11/10 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
242 Wianno Avenue
Property Address
.Michel Mangalo
Owner Owner's Name
information is S. Dennis MA 02660 04/07/13
required for
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(� Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
1� Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm'level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System•Page 11'd 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
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 even w/ (2) outlets
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.): i
d-box level, no solids, liquid even w/outlet invert, no signs of leaks, d-box located under floor in shed.
Access thru floor cutout. Recommend riser for future access.
tPump 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page Ulof 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
(2) 6' radius w/2'
® leaching pits number. stone around
❑ 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.):
Med sands, no signs of hydraulic failure; no ponding; damp soil or abnormally lush vegetation, bottom
of both SAS leaching pits estimated at 9'6 below grade. Snake camera indicates liquid depth at 24"
in both pits and available leaching volume. Clean sidewall appears to be18-22" below invert in pipe.
`!y 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•11/10 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w ,..'' 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owners Name
information is required for S. Dennis MA 02660 04/07/13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
IPrivy (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.):
i
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°7M 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
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
fJ1tcS-e Se �e, S1
i
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts `
= Title 5, Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:- 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
❑ Observed site ;abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Reviewed engineering plan and prior inspection
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
Reviewed USGS topo and water resource maps
You must describe how you established the high ground water elevation:
Bottom of both SAS estimated a 9.6' below grade.Septic inspection via James M Ford 11/29/04
indicates ground water at 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Wianno Avenue
Property Address
Michel Mangalo
Owner Owner's Name
information is required for S. Dennis MA 02660 04/07/13
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria.Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
it .
d
3
v O> 5
242 Wianno Ave Q
Osterville, MA
B
A
3
0 - 0 4
1 2 Shed
1500 gallon
septic tank
D-Box
Al - 11,5' B1 - 15'
A - 19,5' B2 - 19'
A3 - 37' B3 - 29'
A4 - 47,5' B4 - 37'
f
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROT_ECTION-
REM ED
F. I
+AP* Trwlvt DEC 14 2004
OJ RCEL ; I k$ JWL ,
�0 r "tOVVN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ,
Property Address: 242 Wianno Avenue ; C
Ostervili;e;MA 02655
Owner's Name: Michel ManQ alo
Owner's Address:' t
Date of Inspection: November 24. 2004 1
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford --
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400 .
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 29, 2004
The system inspector shall subL 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.
i
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
IL
r
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 242 Wianno Avenue
Osterville. AM'
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined Y N ND in the for the following
( ) o lowing statements. If not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel ManQalo
Date of Inspection: November 24. 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety.and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ . The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 242 Wianno Avenue
Osterville. MA
Owner: Michel Manzalo
Date of Inspection: November 24, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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
p SAS or cesspool
gg
✓ 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'/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 well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or 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.
4
' Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Manzalo
Date of Inspection: November 24, 2004
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:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION
Property Address: 242 Wianno Avenue
Osterville. MA
Owner: Michel Man alo
Date of Inspection: November 24. 2004
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 6 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 4
.Does residence have a garbage grinder(yes or no): ' n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2003-242,000 gals.:2002-317.000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:.
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool .
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed in 1991 -per owner
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel ManQalo
Date of Inspection: November 24, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 28"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 12"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 8"
How were dimensions determined: Measuring stick
Commnents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert There did not appear to be an signs igns of leakage. The inlet
cover was 12"below grade. Recommend pump
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville, MA
Owner: Michel Manzalo
Date of Inspection: November 24, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
T �
YPe
✓ leaching pits,number: _2-4'x 6'(600 gal.) w/2'stone-per design plans
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology: r
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
One it(#1 was under a shed. The i2it had 1.5'o li uid on the bottom. The scum line was 2'up from the bottom. There did not
appear to be any signs of failure. The other nit 02) had 2'of liquid on the bottom The scum line was at the same level The
it was under the driveway. There did not appear to be any signs o[failure A video camera was used to inspect the nits
CESSPOOLS: None (cesspool must:be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Ostervi_lle, MA
Owner: _ Michel Manealo
Date of Inspection: November 24, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate whore public water supply enters the building.
J
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10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Avenue
Osterville: MA
Owner: Michel Mangalo
Date of Inspection: November 24, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps, the maps were showing approximately 20'+1-to ground water at this
site. Usingthe he Cape Cod Commission technical bulletin, the high ground water adjustment for this site(MIW 29,Zone A, 10104)
was 2.2'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection andlor this report.
11
Conunonwealth of Massachusetts
' Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
One winter Street, Boston,Ma. 02108. .John Grad
D.E.P. Title V Septic Ins ector
P.O. Bo 1
Teatick 2 3' 2
WILLIAM F.WELD (50 -6813 w
Governor RECEIVED
ARGEO PAUL CELLUCCI
Lt.Governor S E P 2 9 199 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '~
PART A TOWNOFBARMTABLE
CERTIFICATION HFAITHDI:PL
Property Address: 242 Wianno Av.Osterville Address of Owner:
Date of Inspection:9/25/97 (If different) 8 jr
Name of Inspector:John Graci Smigowski:Box 375 Osterville Ma.02635
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
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 This inspection is based on criteria defined in Title V
— Conditions y Pa ses code 310 CMR 15.303.My findinqs are of how the system is
Needs Fu er performing at the time of the inspection.My inspection does
aluation 8y the Local Approving Authority
not imply any warranty or guarantee of the longevity of the
Fails
- I septic system and any of its components useful life.
y f
Inspector's Signature: p% Date: 9/26/97
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
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 conforming septic tank
as approved by the Board of Health.
(revised 04/27/97)
One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 242WannoAv.Osterville
Owner: Smigowski:Box 375Osterville Me.02635
Date of Inspection:9/25/97
_ Sewaae backuD or.breakout.or hiah.static water level observed.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 waters upply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private watersupply 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.
(revised 04127/97)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION (continued)
Property Address: 242 WiannoAv.Osterville
Owner: Smigowski:Box 375 Osterdle Ma.02635
Date of Inspection:9125/97
Dj 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.
Ej 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 260 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)
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.
w
(revised 04/27/97)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 242 WiannoAv.Osterville
Owner: Smigowski:Box 375 Osterville Me.02635
Date of Inspection:9/25/97
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_y_ — 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.
_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.
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.
X Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
unacceptable)115.302(3)(b)j
k
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 242 WiannoAv.Osterville
Owner: Smigowski:Box 375 Osterville Me.02635
Date of Inspection:9/25/97
RESIDENTIAL:
FLOW CONDITIONS
-
Design flow: 440 g•p.d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 3
Garbage grinder(yes or no): Yes
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):
n/a
Sump Pump(yes or no): No
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:0 gallons/day
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
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: 1
System has not been pumped in the last year.
System pumped as part of inspection: (yes or-no)Yes
If yes,volume pumped: 1500 gallons
Reason for pumping: Maintenance.
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:
1993
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242WiannoAv.0sterville
Owner: Smigowski:Box 375OsterAlle Ma.02635
Date of Inspection:9125/97
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 3'
Material of construction:X concreate_metai FRP Polyethylene_other(explain)
If tank is metal, list age o . Is age confirmed ertrf by Cicate of Compliance No (Yes/No}
Dimensions: L 10'6"H 5'7"W 5'B•
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 15"
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.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_metal_FRP_Polyethylene other(explain)
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,va
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.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 3'6^
Material of construction:—cast iron X 40 PVC,_,other(explain)
Distance from private water supply well or suction lin0own
Diameter: 4•
rn/amments:(conditions of joints,venting, evidence of leakage,etc.)
(revised 04127/97) t
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Wianno Av.Ostervilie
Owner: Smigowski:Box 375 Osterville Me.02635
Date of Inspection:9/25/97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: We
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm level:_nhk Alarm in working order?_Yes_No
Date of previous pumping:
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:-Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
D•box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.) `
n/a
(revised D4/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 WiannoAv.Osterville
Owner: Smigowski:Box 375Osterville Ma.02635
Date of Inspection:9125/97
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:
n/a
Type:
leaching pits,number: 2-1,000 gallon leach pit
leaching chambers,number:n/a
leaching galleries, number: n/a
leaching trenches,number, length: n/a
leaching fields; number, dimensions:n/a
overflow cesspool,number:n/a
Alternate system: n/a Name of Technology:_n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The overflows are structurally sound and functioning property.The leach pit D was empty and the pit E was unaccessable and under asphalt.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r
n/a
PRIVY:_
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
We
(revised 04/27197)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
242 Mann Av.Osterville
Smigowskl:Box 375 Osterville Me.02635
925/97
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)
A
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(revised WNW) Page 0 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
242 Wianno Av.Osterville
Smigowski:Box 375 Osterville Ma.02635
9/25/97
q •
Depth of groundwater tz+
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 04/27/97) page 10 of 10
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