HomeMy WebLinkAbout0459 WIANNO AVENUE - Health 459 WIANNO AVENUE
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Postage&Fees Paid
USPS
` Permit No.G-10
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9590 9402 �F'14P 69 1908 45
United States •Sender.Please print your name,address,and ZIP+4®in this box•
Postal Service
taa"a Town of Barnstable
' Health Division
k �
zu 0 Main Street
Hyannis,MA 02601
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-- _- �_- very.
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( ELLSWORTH, DAVID JR&GOTTFRIED, LUCINDA
I 4 AVON STREET
ANDOVER, MA 01810 j
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ertified Mail Delivery
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PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
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rr- ELLSWORTH, DAVID JR&GOTTFRIED, LTC]
to 4 AVON STREET
o ANDOVER, MA 0 1810
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Ps Form 3800,April 2015(Reverse)PSN 7530-02-000.9047
�sTti Town of Barnstable
Inspectional Services
aAANSTAB1.L
3 09. Public Health Division
i6 �0
p 200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4988 0756
April 3, 2020
ELLSWORTH, DAVID JR&GOTTFRIED, LUCINDA
4 AVON STREET
ANDOVER, MA 0 18 10
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 459 Wianno Avenue, Osterville, MA was inspected on
02/07/2020 by Shawn Mcelroy, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic systern.showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• The laundry/bathroom cesspools have decay and stain lines above invert.
You are ordered to replace the septic system within sixty (60) days from the date you
receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mai ling\Conditionally Passes Letters\459 Wianno Ave Osterville.doc
Town of Barnstable
+ IIARNSTAHLE,
MASSa 1679. Inspectional Services Department
`g�
- Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINESTO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the o is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion.of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
0 HER
G v. �� ✓c �Od(i.. ,r Cl ✓ rn /r/Y to I C1 ba ve %ni,er
Repair deadline: O d rr ,
0:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Tripp,Vanessa
From: Crocker, Sharon
Sent: Thursday March 26, 2020'12:59 PM
To: Tripp,Vanessa; Stanton, David
Subject: 459 Wianno Ave, Osterville - Septic Inspection Report Revision
*3/26/2020-Shawn McElroy found there is another system in back which needs to be connected to front by a
pump chamber-according to him.
He will be sending in a revised 'Cond.Pass." report within the next few days.
Sharon
1
To whom,
T
This is a revised report that was originally filed on 2-7-20.
i A
There were two laundry/bathroom cesspools that were discovered after this
report was filed. After examining those cesspools it was found that they had similar
issues with decay as well as stain lines above the inverts.
The end result is still the same. A"Conditional Pass"for the system, as the leach pit in the front of the
house is still in great shape.
I have discussed with the owner that along with replacement of the cesspool
In the front of the house,that the plumbing from the side of the house needed to
be re-routed to connect with the plumbing and septic tank in the front of the house.
Options to achieve that goal have been discussed and will be the owners decision.
Thank you,
;Shga !!�
Upper Cape Septic
r Commonwealth of Massachusetts
Title 5 Official Inspection Fora
it Subsurface Sewage Disposal System Form Not for Voluntary Assessments -
459 Wianno Ave �.
Property Address h
Lucinda Gottfried & David Ellsworth �
{ ; f t.3
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20 - Gt
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. ,
A. Inspector Information , . l IH8Q0
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth g,, , ;:rt ,� ,^ , - ,, ` . .., } MA t -02536
City/Town State Zip Code
1-508-495-0905 S 13971
Telephone Number License Number
B. Certification
I certify that:) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time.of my inspection; and
the inspection was"performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection'l have determined that
the system:
1. El 'Passes `;p x , . ` t #,. n o , . 7,4
2., ® Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
. , 2-7-20
Inspector's Signatur Date
_ The'system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, t6e'inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018. 3. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18. -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Vint Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth '
Owner Owner's Name
information is
required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
,1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
There is a precast leach pit in the front that in good working order.
2) System Conditionally Passes:
® One or more system components as described in the "ConditionalPass" 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" ff, 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):
There is 4'x4' block cesspool acting as the main tank that is in poor condition with blocks starting to
shift and fall. There are also two 6x8 block cesspools on the side of the-house that have signs of
failure and should be abandoned with the plumbing routed to the front system.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
f Title 5 Official Inspection Form' -f
,�l Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments
459 Wianno Ave
Property Address „
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every -
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) ►, �,t '� ~,
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired: '
• i '.t• ..:" 1 .. ' .j IDS .� .i{' «,e -r ii r,.. f �+tv ..,
❑ 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): r
❑ ' '- broken pipe(s)"are replaced ^'` '' `` *='❑ Y ❑N ❑'ND (Explain below):
I ❑ '` obstruction is removed r' �' ❑ 'Y '❑N 0 ND (Explain below):
` ❑ '` a distribution box is leveled or repiaced ;r❑Y ❑ N ❑-ND (Explain below):
,,, a-i
F 1' Ilk
❑ 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 _ by
❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health: .
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
t safety and the environment:
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
i�► Subsurface Sewage Disposal System Form -Not for Vol untary'Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water `
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: A
❑The system has a septic tank and soil absorption.system (SAS) and the SAS is within
100 feet of a surface water'supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems: -
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes = No ?. .
7 Backup of sewage into facility.or system component due to overloaded or
El ® clogged SAS or cesspool 1.
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
I
Commonwealth of Massachusetts r • i .z
Title 5 Official Inspection Form x
W'i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .
459 Wianno Ave
Property Address ,
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every OStervllle :_••; MA 02655 2-7-20 �.
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) *_ x
4) System Failure Criteria Applicable to All Systems: (cont.) ,
Yes No
"® t .Static liquid ievel in the distribution box above'out_let 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
❑, ,^ ® •thanM aay flow ' _ - • • '
❑� ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: "
❑ ® ;Any portion of the,SAS, cesspool.or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
❑ ' "► ® tributary to a surface water supply.--
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
,- ❑ r ®, }' well. � ..
Any'portion of a cesspool'or privy is within 50 feet of a private water supply well.
'❑ ` ®, '''Any portion of'a cesspool or privy,is less than 1'00 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the.well.water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of;ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
,t • „: t and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
,., ® 10,000 gpd. - . .
The system fails.tI have`deteAined that one or more of the above failure
�' ❑ ®� criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the.Board of Health to determine what will be
necessary.to correct the failure.:, ,
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes or"no"to each of the,following, in addition to the
questions in,Section C.4:
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts t
3 Title 5 Official Inspection'Form
,ill Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r� 1<
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every '
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes;"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the'appr'opriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note.as:N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
E ❑ 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,
t
dimensions, depth of liquid, depth of sludge and depth'of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria,related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5iisp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection .Form., y r
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments_i
459 Wianno Ave CProperty Address ,
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Cisterville
required for every MA 02655 2-7-20,
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: t , ,,.� . , w r. ,. ,
Number of bedrooms (design): N/A Number of bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Description:
t i
t Number of current residents: _ 4 0
Does residence have a garbage grinder? a ., _,4, ,. , . ,,, ;� ❑ Yes ® No
Does residence have a water treatment unit? y,; ► , ;._ ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.) ` `` `°
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
,• _ .,:_, : . .„fir , , r . ttr�f , . - -
Sump pump? v , ❑ Yes ® No
2019
Last date of occupancy: r::'t: t• _ F �.< '<'' Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts '
r Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every A=
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): " Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts + , �• - ,
;w Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F.• >c'
:nr-,-•T, , 459 Wianno Ave
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name 1
information is Osterville- MA 02655 2-7-20
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® ' Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool.
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract ;4
❑ Tight tank.Attach a copy of the,DEP,approval. /
® Other(describe):
Block cesspool with 1000 gal leach pit.
Approximate-'age of all components, date installed (if known) and,source of information:
Cesspool 1960's with leach pit added in the 1978
Were sewage odors detected when arriving at the site?.a4; r , ❑; Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 36" at front system. 60" side system
feet'
Material of construction:
`-r _
® cast iron' 4 �®"40 PVC ' ®•other(explain): Orangeburg
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting; evidence of leakage, etc.):
Good condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
}� I. Title 5 Official Inspection Form
i,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth -
Owner Owner's Name
information is Osteryille MA 02655 2-7-20
required for every `
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: Cover on grade
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 4x4 block cesspool
Sludge depth:
0
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness 0
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 NN
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Block cesspool was empty at inspection with signs of decay. Blocks are starting to shift.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts ... f.
4. 1" Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. �.
459 Wianno Ave f
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is t
required for every Osterville MA 02655 2-7-20,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:, _ ;
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
f.,
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete El 'metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
s Commonwealth of Massachusetts '
I��� Title 5 Official Inspection Form
w.
C.l Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�.. T, ? 459 Wianno Ave }
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
e. City/Town State Zip Code Date of Inspection
page. P
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)(locate on site plan):.
Depth of liquid level above outlet invert N/A
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
3� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
459 Wianno Ave r
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name ri
information is
required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
10. Pump Chamber(locate on site plan):
Pumps in working order: "�'' '' ❑ Yes ❑ No*
Alarms in working order: r fir' ' `' `'' ' ' ` ''❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type: ,`• ..
® leaching bits•• ` number: ' 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries - number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1-6x8
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
y Title 5 Official . Inspection Form
wa
�rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S.J ? 459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with no sign of ever being used.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2-inline side system
Depth—top.of liquid to inlet invert Empty
Depth of solids layer 0
Depth of scum layer 0
Dimensions of cesspool 6x8
Materials of construction block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Block cesspools empty at inspection with signs of decay.
F
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
i, Subsurface Sewage Disposal System Form--Not for.Voluntary Assessments i
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
- •
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) • -
13. Privy (locate on site plan): r
Materials of construction:
Dimensions.4:
Depth of solids
t Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
f
•4
i
k
F
F
r•
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts i
3 Title 5 Official Inspection -.Form
ii
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
S�•T,y 459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every '
page. City/Town • - State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
3
__ 00
� a
(Ye
Al
J 34
�K
G
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form i
MI Subsurface Sewage Disposal System Form,-,Not Not for Voluntary Assessments
9 p Y ►Y
459 Wianno Ave
Property Address
Lucinda Gottfried &David Ellsworth r t, 4 r t
Owner Owner's Name
information is required for every Osterville '` r i MA 02655 2-7-20 t.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) )
15. Site Exam:
❑ Check Slope x
❑ Surface water ?• , t+ - , _ . rx,}. _ .
❑ Check cellar -
❑ Shallow wells
Estimated depth to high ground water:,, 't + j w 20feet
Please indicate all methods used to determine the high ground water,elevation:
❑ Obtained from_system design plans on record YJ , +
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet,of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
s Commonwealth of Massachusetts
,w, Title 5 Official Inspection Form
�,i. Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
y� :�n
� ?. .> 459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every '
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information: : P - • , . .
For 8: Tight/Holding Tank—Pumping contract attached '
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
�tT Town of Barnstable
.� Inspectional Services
1AXN8TABLE. ,
'"ASS.
039. Public Health Division
�0
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304 .
CERTIFIED MAIL#7015 1730 0001 4988 1487 , y
March 9, 2020
ELLSWORTH, DAVID JR&GOTTFRIED,.LUCINDA
4 AVON STREET
;MA 01810 ANDOVER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system.located at 459 Wianno Avenue, Osterville was inspected on
02/07/2020 by Shawn Mcelroy,certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• The main cesspool is in poor condition with blocks starting to shift and fall.
You are ordered to repair or replace the septic system within sixty (60)-days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH = .
Th—Tina ean, R.
Agent of the Board ofHealth.
Q:\SEPTIC\Title V Inspection Report Letters Mai ling\Conditionally Passes Letters\459 Wianno Avenue Osterville.doc
of 1HF r
Town of Barnstable
UAWNSfAHLE, • -
Inspectional Services Department
TfD MA'S�
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed.
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any.portion of the SAS; cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within,a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
(nr/1 (e`J Ua l "', Oof �Fn W t J o ck
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
a7-
��' Commonweailth of Massachusetts _ . I �
Title 5 Official Inspection Form
'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t
�r >" 459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is
required for every Osterville MA 02655 2-7-20
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information
Shawn Mcelroy
Name of Inspector -
Upper Cape Septic Services
Company Name
P.O. Box 73 r
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in.full compliance with Section 15.340 of Title 5
(310 CMR 16.000);1 have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
' the inspection was performed based on my training and experience'in the proper function and
maintenance of on-site sewage disposal Systems.After conducting this inspection I have determined that
the system:
1. ❑ Passes'
r� t. ,, r .. - F :. ,._,'•,
2. ® Conditionally Passes
3. '❑ Needs Further Evaluation by the Local Approving Authority ,,
4. ❑ Fails
2-7-20 -
I ector's Signature Date
The system.inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
%
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
r
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1.) System•Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
® One or more system components as described in'the "ConditionalPass" 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 ON ® ND (Explain below):
There is 4'x4' block cesspool acting as the main tank that is in poor condition with blocks starting to
shift and fall.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection ForM, . '
i,�F Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments. r
459 Wianno Ave
Property Address ,
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is
required for every Osterville MA 02655 2-7-20 -
page. City/Town w State Zip Code Date of Inspection
C. Inspection Summary (cont.) �; , • ,
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if'(with approval of Board of Health): "
El ' broken pipe(s) are replaced El `❑N''' El ND (Explain below):
El Aobstruction is removed ''`' ❑ Y ❑N ❑_ND (Explain below):
❑ distribution box is leveled or replaced` ❑Y ❑ 'N ❑ ND (Explain below):
,f
❑ 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 ON ❑ ND (Explain below):
❑ obstruction is removed y ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:'. t.
❑ Conditions exist which require further evaluation by.the Board of Health in order to determine if
'}the system isrfailing'to protect public health, safety or the environment.- — `
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: t
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18-
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form,
w:
+ I'll Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every '
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) t, -
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less.than 100 feet but 50 feet or
more from a private water supply'well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to`each of the following for all inspections:
Yes No .
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection -,Form
�i Subsurface-Sewage Disposal,System Form,-'Not for Voluntary Assessments
459 Wianno Ave ,
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name r
information is .s.
required for every Osterville MA 02655 2-7-20 i'
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.) 3R ; ►•# _.
4) System Failure Criteria Applicable to All Systems:.(cont.) ; .• ,,, -' ,
Yes • ..No
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ _ ® tha6'%day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El ® ti :Any portion of the SAS, cesspool:or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply. '
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
❑ ' '® well: ,.a ►
'' ' ❑_' ® i Any portion of a cesspool or,pdvy is'within 50 feet of a private water supply well.
❑"" ®" `Afiy 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
r - system passe&if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
• of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and.chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 gpd-
,000 9P.
❑ 10 d. '
_
The system fails. I have determined that one or more of the above failure
❑ ' ''; ® * criteria exist as described in 316 CMR•15.303, therefore the system fails. The
system ownershould contact the Board of Health to determine what will be
_ , •,.�. t necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd. '
For large systems, you must indicate either," es7or"no"to each of the following, in addition to the
questions in Section CA.-
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
6e Commonwealth of Massachusetts
iI
Title 5 Official Inspection Form
w..
0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Cisterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) I - + . 4. . ..
If you have answered "yes"to any question in Section C.5 the system is`considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No ;
❑ ® < Pumping•information was'provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water,been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
- ® ❑ Was the facility or dwelling:inspected for signs of sewage back up?
• ®' ❑ -was the site inspected for signs of break out?
r•.
® ❑ Were all system components,'excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
t inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5irsp.doc•rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
,a ,w Title 5 Official Inspection Fora, A . .
i-'l Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
,.fol
459 Wianno Ave
Property Address r
Lucinda Gottfried &David Ellsworth -r+ f
Owner Owner's Name ,
information is
required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information ; , T•:
1. Residential Flow Conditions: ,..:
Number of bedrooms (design): N/A Number of bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Description:
Number of current residents: ° + - :: _: 0
Does residence have a garbage grinder?.,f ❑ Yes ® No
Does residence have a water treatment unit? :; .. , f ,a ,�: . ° ❑ Yes ® No
If yes, discharges to: ,
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail: ,
Sump pump? y .*, q• ❑ Yes ® No
2019
Last date of occupancy: k. .;=f+ ; k . Its' Date Date
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
;yI'll Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments
r a
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5ins .doc-rev.7/26/2018 Title 5 Official I n F r PInspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts t
3 Title 5 Official Inspection Form
"i l Subsurface Sewage Disposal System Form -Not for,Voluntary.Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth r ,
Owner Owner's Name
information is required for every Osterville , f _ MA 02655 2-7-20 � _. '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) s
4. Type of System:
® Septic tank, distribution box, soil absorption system
® Single cesspool
❑ Overflow cesspool + ,
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Night tank.Attach a copy of the.DEP approval.,.--
Other(describe):
L Block cesspool with 1000 gal leach pit.
r -
Approximate age of all components, date installed (if known) and source of information:
Cesspool 1960's with leach pit added in the 1978
Were sewage odors detected when arriving at the site? _ ❑ Yes ® No
5. Building Sewer(locate on site plan): �t
_
Depth below grade: 36"feet
: . :• ., •, , -,.-�, F .-. tit,,
Material of construction:
t - Orangeburg '
n cast iron ® 40 PVC ` ® other'(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
s Commonwealth of Massachusetts
Title 5 Official Inspection Form
'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Ostefville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: Cover on grade
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate] ❑ Yes ❑ No
Dimensions: 4x4 block cesspool
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness 0
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/V
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Block cesspool was empty at inspection with signs of decay. Blocks are starting to shift.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form--'Not for Voluntary Assessments i
459 Wianno Ave �� •�, �}
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name ,
information is
required for every Osterville i MA 02655 2-7-201 a
page. City/Town State, Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan): ► L+ j=•..
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: t. f , Date
Comments (on pumping recommendations,-inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade: -
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Iryi Subsurface Sewage Disposal System Form Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
(page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tig
ht or Holding Tank (cont.)
Alarm present: ❑ Yes ❑• No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts 1 -
- ,. Title 5 Official Inspection Form
�M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 9 p Y rY
-c
459 Wianno Ave -
Property Address ; ..
Lucinda Gottfried &David Ellsworth 11,
Owner Owner's Name
information is r
required for every Osterville r" t MA 02655 2-7-201' f'
page. City/Town •_ State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: u "y` '` ❑ Yes ❑ No*
Alarms in working order: .. '❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass. -
11. Soil Absorption System (SAS) (locate on site plan, excavation-not required):.
If SAS not located, explain why: t
Type:
® _ 1-1000 gal
leaching pits' number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
► Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments.
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is Osterville MA 02655 2-7-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with no sign of ever being used.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
i
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form'
i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
page. City/Town _ State Zip Code Date of Inspection
D. System Information (cont.)
e
13. Privy (locate on site plan): Or
Materials of construction: ,
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,
•
i
• 1:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts ry
1,� Title 5 Official Inspection Form
w.,
"'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Wianno Ave
Property Address
Lucinda Gottfried & David Ellsworth
Owner Owner's Name
information is required for every Osterville MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
f
r
f
E
f
43Y? a IP
B . ,Q , 3
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official- Inspection Form" wr
�. Subsurface Sewage Disposal-System Form Not for Voluntary Assessments _ r„
459 Wianno Ave '-
Property Address
Lucinda Gottfried & David Ellsworth
Owner
Owner's Name
information is Osterville MA 02655 2-7-20 .
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope ;, . _ ► .r�►)
❑ Surface water rt , w r: • ;
❑ Check cellar
❑ Shallow wells V* T
Estimated depth to high groundwater: , , L!7., _ e0et
Please indicate all methods used to determine the high ground water elevation:_
❑ Obtained from system design plans on record '+ t
If checked, date of design plan reviewed: `, Date `
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
r
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r >°' 459 Wianno Ave
Property Address
Lucinda Gottfried &David Ellsworth
Owner Owner's Name
information is required for every Osteryille MA 02655 2-7-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
r.
1 •
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
2T,
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME & ADDRESS
B UILDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
' �� ��
i
i � i
��
t!/�VL
: V V
No............/,�f Fss............._.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARQ OF HE `LTH
.....................................
Appliration for Disposal orks' Tonstrnrtinn ramit
Application is hereby made,for a Permit to Construct ( ) or Repair anIndividual Sewage Disposal
System at:
----- ----- -----------
Location-Address or Lot No.
w
�.... .. . .......... . �t�........------........... ...................................................J Owner ..:: Address- ......................
W "
Instal er Address
vType of Building r -r „,• r _ Size Lot............................Sq. feet
g— """.A4 ._ Expansion Attic ( ) Garbage Grinder ( )Dwelling No.`of Bedrooms ____________________
aOther—Type of Building ................................ No. of persons............. ......... Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------•---------------------------------------------------------•----------------...-----•-----------..........._...
W Design Flow............................................gallons per person per day. Total daily flow................._._................__....:_gallons.
WSeptic Tank—Liquid*capacity............gal_ons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dossing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i, Test Pit No. 2................minutes.per inch Depth of Test Pit.................... Depth to ground water........................
P4 ----------------------------------------------•------------•-------------------....
0 Description of Soil........................................................................................................................................................................
W -------------
------------
•--••-•--------------------------------------------
------------------
•----------q-------------------•------• --•----•----------------. -•.......----------
x -----------•......................•-•-------------------------••-•-•-••------------------•------••---•-----. ------- ii
t, Nature of Repairs or tions—Answer when applicable...� Y
_. ..
��--�✓- .... ---- -------•-------------------------------------------------------------------------------- -
Agr : IV
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State 'Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has issuedy the bo d 1 lth.
Sign ��--!�--'-� �.�-�� .--- -- ---y�--
Date
ApplicationApproved By................................................................................................... ........................................
Date
Application Disapproved for the following reasons:-------•--------------•--------•----------------------------.................................................
...........-•-•------------------•••-•-----.-•-••-••-•-•---------•--••.......-•--------•-....------------•----------•-----------------------•-----------------•--•--------•-•---...-•---•--•------------
Date.
Permit No...................... - ---Issued_.... ...