HomeMy WebLinkAbout0557 WIANNO AVENUE - Health Ls
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TOWN OF BARNSTABLE
-":LOCATION 551 SEWAGE#
VILLAGE GSf VI" ASSESSOR'S MAP.&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS S
OWNER P uAPriDN a elgW
PERMIT DATE: 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 orr
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
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SOLUTIONS SCALE
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Town of Barnstable P#
Department of Regulatory Services
aFIME Public Health Division Date o
200 Main Street,Hyannis MA 02601
BARNSTAB Fee Pd. lQ
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MASS. �y
1659•�b ,� Tillie - �°rEo►�txl• Date Scheduled
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Soil Suitability"Assessment for.Sewag 'Disposal
Performed By: Larry Carreiro _ Witnessed By: `� I
LOCATION,& GENERAL INFORMATION
Location Address Owner's Name:Peggy Plimpton
557 Wianno Avenue,Osterville
Address:423 Sandy Valley Road,Westwood,Ma.02090
Assessor's Map/Parcel: 162-014 Engineer's Name:Holmes&McGrath,Inc.
205 Worcester Court,Falmouth MA.02540
NEW CONSTRUCTION . REPAIR.- X • y - Telephone 11,1-508-548-3564 w _
Land Use _Residential GAS Slopes(%) 2 — 5 Surface Stones NO
Distances from: Open Water Body 0 V ft Possible Wet Area ft Drinking Water Well ft
Drainage Way — ft Property Line 2�-f ft Other , ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
of
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Parent material(geologic) Ci Gl UUTW A S/4 Depth to Bedrock '✓��t
Depth to Groundwater: Standing Water in Hole: IVD NE•. Weeping from Pit Face
Estimated Seasonal High Groundwater •eL,e v. 3.o
DETERMINATION'FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
_ PERCOLATION TEST Date Time
Observation
Hole# Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ Time{9"-6')
End Pre-soak
Rate Min./Inch SGl+/ 50rnple 61tfV6 qugLys�S
Site Suitability Assessment: Site Passed ) Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----=----
Q:HEALTH/W P/PERCFORM
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,' z1 DEEP OBSERVATION HOLE LOG Hole#
Depth'from, Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel)
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C 411�!d- 5G nd 2-5y 16 — 51�ile 9r'ol'n, ldose
DEEP OBSERVATION HOLE LOG. Hole# 2
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel)
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30. JFu 15 k0amySgOeY 51�
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DEEP OBSERVATION:HOLE LOG Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year boundary No✓ Yes
Within 100 year flood boundary No `� Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area
proposed for the soil absorption system? Ye S
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on N OV, 2.00 6 (date)I have passed the soil evaluator examination approved by the Department of
Environmental Protection and that the above analysis was performed by me consistent with the required training,
expertise and experience described in 310 CMR 15.017.
Signature G>✓S Ji W Date
Q:HEALTH/WP/PERCFORM
��j try Town of Barnstable
' Regulatory Services
w ' AS `M & Public Health Division
,y MASS.
039.
e. Thomas McKean,Director
206 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
NOTE TO FILE REGARDING: 557 WIANNO AVENUE, OSTERVILLE
9/20/18 Jim Ford called Tom McKean. The septic system passed his
inspection on December 7, 2016.. However, "there is no way to determine the
capacity of cesspools constructed of blocks. The leaching pit, or cesspool, was
"bone dry" per Jim Ford;�`He was asked to make a determination by the owner's
attorney, Albert Schulz. The Assessor's Department lists this property as having
five bedrooms. Mr. McKean informed Mr.`Ford that the determination of the
grandfathered bedroom count is not the inspector's responsibility.
9/20/18 Attorney Albert J. Schulz submitted a package of information on the
property. The floor plan shows 15 existing bedrooms and an affidavit has been
received from Priscilla Murphy, whose parents owned the property for many
years, stating "15 bedrooms have been used from time to time, seasonally, from
the period of 1979 through 2013".
Given this information, this property, 557 Wianno Avenue, Osterville is
grandfathered for 15 bedrooms, however, the system capacity.needs to be
determined by a professional engineer or registered sanitarian in the event of a
proposed expansion of the dwelling as per section 360720 of the Town of
Barnstable Code.
Signed Date: 2.1 I
Thomas McKean, Director
Health Division
Q:\WPFILES\557WIANNO AVENUE OSTERVILLE bedroom count 9-21-18.docx
SCHULZ LAW OFFICES, LLG
THE SAMUEL ISHAM HOUSE C'
P•,
1340 MAIN STREET
OSTERVILLE, MASSACHUSETTS 02655-1542
TELEPHONE(508)428-0950 :d
FACSIMILE(508)420-1536 X
ALBERT J. SCHULZ MICHAIMF.SCHULZ
aschulz@schulzlawoffices.com mschulz@sch Lawoffices.com
September 20, 2018
Thomas McKean, Director
Town of Barnstable Board of Health
200 Main Street
Hyannis, MA 02601
Re: 557 Wianno Avenue, Osterville
Our File No. 23677
Dear Mr. McKean:
I enclose the Affidavit of Priscilla P. Morphy concerning the existing septic system on the above
captioned property, which was inspected by James Ford, Ford Septic Services, on December 27,
2016. At the time of Mr. Ford's inspection he did not have access to the premises and relied on
the Assessing Department information that the premises contained five (5) bedrooms. The
enclosed Affidavit is filed in response to a conversation between you and Mr. Ford yesterday
afternoon concerning the fact that the premises actually contains fifteen (15) bedrooms.
Should you have any questions or comments regarding Ms. Morphy's Affidavit, please do not
hesitate to contact me.
Sincerely,
Albert J. Schulz
AJS/ssm
Enclosure
cc: Priscilla P. Morphy
� I
AFFIDAVIT
I, PRISCILLA PLIMPTON MORPHY, of Vero Beach, Florida, on oath depose and state the
following to the best of my knowledge and belief-
1. I am fifty-nine (59) years of age and presently reside in Vero Beach, Florida.
2. I have personal knowledge of the statements made herein.
3. My parents, Hollis W. Plimpton,Jr. and Peggy L. Plimpton,purchased the real estate at
557 Wianno Avenue, Osterville (Parcel 14 on Assessors Map 162) from John P
Birmingham, Jr. and Karen E. Birmingham on February 20, 1979. See Exhibit 1 and
Exhibit 2 attached hereto. For estate planning purposes,title to the property was placed
in my mother's name solely in 1984. See Exhibit 3 attached.
4. At the time my parents purchased the property in 1979, an on-site septic system with
three (3) cesspools existed on the property. A sketch showing the location and alignment
of the cesspools is attached hereto as Exhibit 4. That same septic system is in the ground
today and was most recently inspected on December 27, 2016,by James Ford of Ford
Septic Services, LLC. I understand that Mr. Ford's Inspection Report has been filed with
the Town of Barnstable Board of Health.
5. Attached to this Affidavit as Exhibit 5 is a plan (3 pages)depicting the rooms on the
ground floor, second floor and third floor of the dwelling as they presently exist and as
they existed in 1979. Fifteen(15)bedrooms are depicted, which have all been used from
time to time, seasonally, by my parents,my family, my sister's family and my brother's
family from 1979 until 2013. During the period from about 1988 to 1995, eight(8) adults
and at least four (4) children resided at the property during the summer months. The
premises has been used only occasionally by my sister's family since 2013.
Signed under the pains and penalties of perjury on this ? day of September, 2018.
Priscilla P. Morphy
EXHIBI T 1
MASSACHUStTTS OUITCLAIM CEED INDIVIDUAL iLONG FOPM1 892
f
John P. Birmingham, Jr. and Karen E. Birmingham, husband and wife, as tenants by the
entirety
of 8 Hillside Road, IVellesley, Nurfolk County,Massachusetts
i
being xcmarried,for consideration paid, and iu full consideration of One Hundy ed and Twenty-Five
Thousand Dollars ($125,000, 00)
rants to Hollis W. Plimpton, Jr. and Peggy Plimpton , husband and wife, as tenants �
Dy the entirety
of 39 Clyde Street, Chestnut Hill, Norfolk County, with tlutirtaim eaurnants
Massachusetts
the land in Barnstable, Barnstable County, Massachusetts
(Description and encumbranca, if tny)
NORTHWESTERLY by the southeasterly line of Washington Avenue, one
hundred seventy-nine and 33/100 (179.33) feet;
Y
NORTHEASTERLY by the southwesterly line of Wianno Avenue, two R.
hundred ten and 71/100 (210.71) feet;
SOUTHEASTERLY by Sea View Avenue, one hundred sixty-one and
93/100 (161 .93) feet; and
SOUTHWESTERLY by Land now or formerly of Helen L. Jones, Two
hundred ten (210) feet.
All of said boundaries are determined by the Court to be located as shown on
plan 14576-A drawn by Newell B. Snow, Engineer, dated October 1930 as modified and
approved by the Court and filed in the Land Registration Office at Boston, a copy
of a portion of which is filed in Barnstable County Registry of Deeds in Land
Registration Book 11, Page Ill with Certificate of Titie No. 2656.
The above described land is subject to restrictions as set forth in a deed
given by Calvin B. Prescott to Ellen W. Garrison dated November 22, 1882 duly
recorded in Book 155, Page 144.
So much of said land as was a part of said Sea View Avenue as originally laid
out is subject to rights of all persons entitled in and over the same so far as such
rights are now in force.
Said land is also subject to the establishment of a building line in Nianno
Avenue by the Town of Barnstable as set forth in Taking dated May 2, 1929 duly
recorded in Book 464, Page 411 .
This conveyance is made subject to and with the benefit of easements,
restrictions, conditions, reservations and agreements of record, if any, insofar
as the same are -zow in force and applicable end to current real estate taxes.
For title reference see Certificate of Title, filed in Barnstable County
Registry of Deeds in Land Registration Book 412, Page 120. 6y
CUMMQN E •.)t 1AA°,'.Af_HUSEiTS
eo Tyi U.ANE1SN
FEB2 11_
is 61)
(•Individual—joint Tenants---Tenants in Common--Tenants by the Entirety.)
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i
ii�lhtraa .......P. ...... hand)and seal, this .......NO............. day of...... ........... ..... ... 1979
............................................................................ .....
John Birmin m J
1G •Y. �ft�: L:�..
Karen E. Birmingham i
. .. . ................................................................. ..................... ,..................................................... .,
k.
Mir (taminanutrut2ll a# fiuoaurljuartia
Suffolk, Ss' February, 2 1979
Then personally appeared the above named John P. Birmingham, Jr.
4
N,1 1111/ I,..
and acknowledged the foregoing instrument to be his free nd decd, J:,�y j
........ . .................NQ
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248174 77354
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EXHIBIT 2
noox 627 rage 4 4
Fonts E•3
Doc. No, 248,174
Zrangfer Certificate of Title. Ctf, No. 77354
From Transfer Certificate No. 51640 Originally Registered June 18, 1971 , in
Registration Hook 412 Page 120 for the Registry District of Barnstable County.
Xbi5 ig to Certifp that Hollis W. Plimpton, Jr. and Peggy Plimpton, husband and
wife, both.of 39 Clyde Street, Chestnut Hill, Norfolk County, Massachusetts 02167,
are
the owner(s) in fee simple, CAUN VELLED
as tenants .by the entirety J
of that land situated in Barnstable
in the County of Barnstable and Commonwealth of Massachusetts, bounded and described as follows:
Northwesterly by the southeasterly line of Washington Avenue, one hund d
seventy-nine and 33/100 (179.33) feet;
Northeasterly by the southwesterly line of Wianno Avenue, two hundred ten
and 71/100 (210.71) feet;
Southeasterly by Sea View Avenue, one hundred sixty-one and 93/100 (161.93)
feet; and
Southwesterly by land now or formerly of Helen L. Jones, two hundred ten
(210) feet.
All of said boundaries are determined by the Court to be loca-
ted as shown on plan 14576-A drawn by Newell B. Snow, Engineer, dated October
1930 as modified and approved by the Court and filed in the Land Registration
Office at Boston; a copy of a portion of which is filed in Barnstable County Re-
gistry of Deeds in Land Registration Book 11 Page 111 with Certificate of Title
No. 2656.
Said land is subject to restrictions as set forth in a deed
given by Calvin B. Prescott to Ellen W. Garrison dated November 22, 1882 duly re-
corded Book 155 Pge 144.
So much of said land as was a part of said Sea view Avenue as
originally laid out is subject to rights of all persons entitled in and over the
same so far as such rights are now in force.
Said land is also subject to the establishment of a building line
in wianno Avenue by the Town of Barnstable as set forth in a Taking dated May 2,
1929 duly recorded Book 464 Page 411.
And it is further certified that said land is under the operation and provisions of Chapter 185 of the General
Laws, and that the title of said Hollis W. Plimpton, Jr. and Peggy Plimpton
to said land is registered under said Chapter, subject, however, to any of the encumbrances mentioned in Section
forty-six of said Chapter, which may be subsisting
WI Ness, WILLIAM 1.RANDALL,Esquire,judge of the Land Court,at Barnstable,in said County of Barnstable.
the twenty-second day of February in the year nineteen hundred
and seventy-nine at 10 o'clock and 46 minutes.
Attest, with the Seal of said Court, c 0 t
Land Court Case No. 14576
STEPHEN WEEKES, Assislaw Recorder.
MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE 77354
DOCUMENT, DATE OF INSTRUMENT
SIGNATURETRECORDER
OF
NUMBER KIND
RUNNING [N FAVOR OF TERMS DATE AND TIME ASSISTANT RECORDER DISCHARGE
OF REGTSTRATION
LAP±s>.PLAN.-I q 57 b—A
CFF.N AA
35a q?,a, b�tuk 811AVA
EXHIBIT 3
Book 812 Page 115
Famm E•3
Doc. No. 352,482
Tranael (Cettificate of Title. Ctf, No, 99595
From Transfer Certificate No. 77354 Originally Registered February 22, 1979 in
Registration Book 627 Page 44 for the Registry District of Barnstable County.
MW iz to Certifp that Peggy Plimpton of 39 Clyde Street, Chestnut Hill,
Massachusetts 02167, is
the owners) in fee simple,
of that land situated in Barnstable
in the County of Barnstable and Commonwealth of Massachusetts, bounded and described as follows:
Northwesterly by the southeasterly line of Washington Avenue, one
hundred seventy-nine and 33/100 (179,33) feet;
Northeasterly by the southwesterly line of Wianno Avenue, two hundred
ten and 71/100 (210.71) feet;
Southeasterly by Sea View Avenue, one hundred sixty-one and 93/100
(161.93) feet; and
Southwesterly by land now or formerly of Helen L. Jones, two hundred
ten (210) feet.
All of said boundaries are determined by the Court to be
located as shown on plan 14576-A dated October 1930, drawn by Newell B. Snow,
Engineer, and filed in the Land Registration Office at Boston, a copy of which
is filed in Barnstable County Registry of Deeds in Land Registration Book 11
Page Ill with Certificate of Title No. 2656.
Said land is subject to restrictions as set forth in a deed
given by Calvin B. Prescott to Ellen W. Garrison dated November 22, 1882 duly
recorded in Book 155 page 144.
So much of said land as was a part of said Sea View Avenue
as originally laid out is subject to rights of all persons entitled in and
over the same so far as such rights are now in force.
Said land is also subject to the establishment of a building
line in Wianno Avenue by the Town of Barnstable as set forth in a taking dated
May 2, 1929 duly recorded in Book 464 Page 411.
And it is further certified that said land is under the operation and provisions of Chapter 185 of the General
Laws, and that the title of said Peggy Plimpton
to said land is registered under said Chapter, subject, however, to any of the encumbrances mentioned in Section
forty-six of said Chapter, which may be subsisting
WITNESS,WILLIAM I. RANDALL,Esquire,Judge of the Land Court,at Barnstable,in said County of Barnstable.
the twenty-fourth day of December in the year nineteen hundred
and eighty-four , at 8 o'clock and 44 minutes.
Attest, with the Seal of said Court, ! t .
Land Court Case No. 14576. - - —
STEPHEN IVEEKES, Assistant Recorder.
MEMORANDA OF ENCUMBRANCES ON THE LAND DESCRIBED IN THIS CERTIFICATE 99595
DOCUMENT DATE OF INSTRUMENT
�1 NUMBER KIND RUNNING IN FAVOR OF TERMS DATE AND TIME ASS SIGNATURE OF ISTANT RECORDER DLSMARGE
OF REGISTRATION
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Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F r +
557 Wianno Avenue r
Property Address
Peggy Plimpton {x.
Owner Owner's Name
information is
required for every Osterville MA 02555 12/7/165
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 forms A. General Information
on the computer,
use only the tab 1. Inspector'
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Ford Septic Services, LLC
„y Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town, State Zip Code
508-862-9400 S12482
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
CONeeds ZFurt Evaluation by the Local Approving Authority
12/27/16 revised 9/25/18 page 6 &7 *'
Insp ct is Signatur Date .
The s tem inspe for shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the'system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent-to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use'
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'•y 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is required for every Osterville MA 02655 12/7/16
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
• r
Commonwealth of Massachusetts
_ w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�A,a,•'' 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
i B) System Conditionally Passes (cont.):
I
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s).are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is required for every Osterville MA 02655 12/7/16
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
1.00 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates'absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
,Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I ,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ N 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.
❑ N 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.]
❑ z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flowof 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
❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area.— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with!310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is required for every Ostetville MA 02555 12/7/16
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
.inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): No Design Number of bedrooms (actual): *'15 see
below
DESIGN flow based.on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): no design
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is r -
required for every Osterville MA 02555 12/7/16
page. CitylTown State Zip Code Date of Inspection!
D. System Information
Description:
**The bedroom count has been revised from 5 to15 per health department. A floor plan and affidavit
from owner has been filed.Original report dated 12/7/16 stated 5 bedrooms per town. Another
inspection was not performed and the house has been vacant for sometime. There is no design flow
on cesspools.**
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) El Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: summer use
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of inspection-
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: maintenance
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f ,
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
system installed -original cesspools
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ® other(explain): clay
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: n/a
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:
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•y' 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'` 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is
required for every Osterville MA 02655 12/7/16
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.):
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):
N/a
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peg y Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present imust 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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition:of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain:why:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 2
❑ 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.):
The overflow cesspools were dry.There was no sign of failure. #2 was made of stone and the cover
was 3" below. #3 was made of bricks and the steel cover was to grade. Both were approximately
6'x6'x10'btg
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 with 2 overflows
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
4"
Dimensions of cesspool 6'wx Tt x 10'bt
Materials of construction brick
Indication of groundwater inflow ❑ Yes ® No
l5ins•3/13 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
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
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.):
The cesspool was pumped for maintenance the cover was 2"
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17
r
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of In
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
A �
1 �� 30
� yy So
3 s'l
3
�r�ut,wQ
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
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: feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
ry Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town 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
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Crocker, Sharon
From: Crocker, Sharon
Sent: Tuesday, September 25, 2018 12:07 PM
To: -McKean Thomas--_._.� —
Subject: 557 Wianno,Ave, Ost~�'`�'
Atty A.Schulz EMAIL: aschulz@schilzlawoffices.com
Tom,
Albert Schulz brought in the revised inspection report from Jim Ford and a letter.
I will leave them in your In-Box.
He asked if you would email him to acknowledge receipt and let him know they would be all set getting sign-off
on a building permit if no additional
Bedrooms proposed.
Thank you.
1
{
SCHULZ LAW OFFICES, LLG
THE SAMUEL ISHAM HOUSE
1340 MAIN STREET
OSTERVILLE, MASSACHUSETTS 02655-1542
TELEPHONE(508)428-0950
FACSIMILE(508)420-1536
ALBERT J.SCHULZ MICHAEL F. SCHULZ
aschulz@schulzlawoffices.com mschulz@schulzlawoffices.com
September 25, 2018
Thomas McKean, Director
Town of Barnstable Board of Health
200 Main Street
Hyannis, MA 02601
Re: 557 Wianno Avenue, Osterville
Our File No. 23677
Dear Mr. McKean:
In accordance with our conversation yesterday afternoon and your instructions to James Ford,
Ford Septic Services, I enclose Mr. Ford's revised Title 5 Official Inspection Form for the above
referenced property. Please confirm that based on this revised Report, the Board of Health will
sign off on the anticipate building permit application for the construction of a new foundation at
the site.
Should you have any questions or comments, please do not hesitate to contact me.
Sincerely
Albert J. Schulz
AJS/ssm
Enclosure
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 557 Wianno Avenue
Property Address "�
Owner Peggy Plimpton
Owner's Name /
information is
required for every Osterville MA 02655 12/7/16
page. City/Town
Fx State Zip Code Date of Inspection Pk7
- ■a
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 A. General Information
filling out forms
on the computer,
use only the tab 1• Inspector:
key to move your
cursor-do not James Ford
use the return
key. Name of Inspector
Ford Septic Services LLC
"d DA Company Name
P.O. Box 49
Company Address
Osterville MA
City/Town 02655
State. Zip Code
508-862-9400 S 12482
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 .
Insprtem
ature 12/27/16
Date
Thenspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of I177 C
O YV
7
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
orm
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ent s
557 Wianno Avenue
Property Address
Owner Peggy Plimpton
Owners Name
information is
required for every Osterville MAC 02655
page. City/Town 12/7/16
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303,or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M a 557 Wianno Avenue
Property Address
Owner Peggy Plimpton
Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N. ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with.310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c`�M a,•'�F 557 Wianno Avenue
Property Address
Owner Peggy Plimpton
Owners Name
information is
required for every Osterville MA
02655
City/Town 12/7/16
page. 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
y tem 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
1.00 feet of a surface water supply or tributary to a surface water supply.
Th❑ e system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic.tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of.the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or Surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1h day flow
t5ins•3/13
Title'5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'•y 557 Wianno Avenue
Property Address
Owner Peggy Plimpton
Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zi Code
P Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water stapply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined'that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the'system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with.a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public wa
ter ater supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered 'yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M a,•'•y 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner I Owners information is Name
required for every Osterville MA 02655 12/7/16
page. Cltyrrown 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 follow
ing:
Yes No
® ❑ Pumping
p g 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?
0 ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms (actual): 5-per town
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): no design
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 557 Wianno Avenue
Property Address
Owner Peggy Plimpton .
Owners Name
information is
required for every Osterville MA 02655 -12/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
cesspools have no design flow
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) El Yes ® No
Laundry system inspected? El Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: summer use
bate-
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? El Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code Date of inspection-
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: maintenance
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):
l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is —
required for every Osterville MA 02655 12/7/16
page. City/Town State Zip Code 'Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
system installed -on cesspools original
Y 9
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ❑ 40 PVC ® other(explain): clay pipe
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
0 concrete ❑ metal ❑fiberglass ❑ polyethylene Y ❑ 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:
Sludge depth:
t5ins•3/13 "
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�A. •' 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is required for every OSterVllle MA 02655 12/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection F'orm
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Ave
nue
Property Address
Owner Peggy Plimpton
Owners Name
information is
required for every Osterville MA 02655 12/7/16
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.):
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 9 polyethylene' El other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13
Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owners Name
information is
required for every Osterville MA 02655 12/7/16
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 ` 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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation riot required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is
required for every Osterville MA 02655 12/7/16
page. City/Town State -ZipCode
Date of Inspection
D. System Information (Cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ - leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number. 2-
❑ 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.):
The overflow cesspools were dry.There was no sign of failure. #2 was made of stone and the cover
was 3" below. #3 was made of bricks and the steel cover was to grade. Both were approximately
6'x6'x10'bt
Cessp
ools p (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 with 2 overflows
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer 4"
Dimensions of cesspool 6'wx Tt x 10'bt
Materials of construction brick
Indication of groundwater inflow ❑ Yes ® No
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Owner Peggy Plimpton
Owner's Name
information is
required for every Osterville MA 02655 12/7/16
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.):
The cesspool was pumped for maintenance the cover was 2"
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of.ponding, condition of vegetation,
etc.):
N/a
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner Owner's Name
information is
required for every Osterville MA 02655 12/7/16
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
1 t� 30
a yy So
3 S'1 Sa'
3
t7r�u�wQ
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
557 Wianno Avenue
Property Address
Owner
Peggy Plimpton information is Owner's Name
required for every Osterville MA 02655 12/7/16
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.
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with'local Board of Health-explain:
Topo and water contours map.
❑ Checked with local excavators, installers'-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
i Title
r50 Officia
l
Inspection Form
Subsurface Sewage Disposal System Form - No
t for VoluntaryAssessments
ssments
'c
557 Wianno Avenue
Property Address
Peggy Plimpton
Owner information is Owner's Name
required for every Osterville MA 02655 12/7/16
page. City/Town State Zi Code
P. 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
5
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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