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HomeMy WebLinkAbout0009 WIANNO CIRCLE - Health (2) 83 West Street e Ostervi l le P „ 6. 139 006 . y v { V i e b x 0 o TOWN OF BA�R�NNSTABLE S\ J LOCATION � \. SEWAGE# VV�ILLAGE Cr�.,�'��, ASSESSOR'S MAP&PARCEL S NAME&PHONE NO.'�Z�, <SIL-V�Orr-6s Y . SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) k r NO.OF BEDROOMS OWNER arc PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY C<<�, �(� � ��� c a��1` �` o.►�i a 42 I i 0, O C C�- act 1, C� .. �� 0 22 TOWN OF BARNSTABLE LOCATION I J UJQS--T S,r SSE# VILLAGE OS'-Q�U 1I tt ASSESSOR'S MAP&PARCEL 'S NAME&PHONE NO.� t SEPTIC TANK CAPACITY /QUO LEACHING FACILITY: (type)"PrT (size) j 000 __XJ NO.OF BEDROOMS OWNER Dokr PERMIT DATE: COS DATE:`.h SPon Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) plv� �� Feet FURNISHED BY 0 ' f / 1 1 f 'i 1•• i f•~r f"r f J r' 1 i 1 '�/ f f r•f f J•,fv f4 f f ! f / f = \ h \ h h h h h 4 +. h + .r4 4 4 4 h k 4 4 h \ \ \ h h h h h'\ -♦ _ f f f f\f 1 ., f h-4 4"% \•4- 4 r 4 +, r +,•`• •kr rh \' 4 \ 4- 4 \ 1 4 '. �4 4 ♦ • / f J f f / / ! J i f f t1 J,�1�f J•f�flf fR 1�1~f f f /f f f•~f !.f ! f / f f 1 f-f f f f 1 1 f f fry f 1 f f.. �• , f ! J J f�•J f / f f f.f f J.J f • ti \ 4 \ h \ \ h 4 \ .\ 8 \f AMA 32 51 63 71 4` 6EWAG ' INSPECTIONS DATE ti 7-j—LAGE ASSESSOR'S MAP & LOT `'-TNSPECPOB jo1 � e �'t� ayy� San In � SEPTIC TPNK CAPACITY LEACHING FACILITY: (type) Lip (size) NO. OF,BEDROOMS -�,� BUILDER OR OWNER +�i�a,ok-f OWNER MAILING ADDRESS n ,• '1•f i f ,b No. © ' O` - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Y ftphtation for Mispo8AY bpstem ConstrUttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(/ ❑Complete System ❑Individual Components Location Address or Lot No. e.�:' �c c�` Owner's Name,Address§,and Tel.No.b r-...., A-4 Assessor's Map/Parcel l3'*% 3 o5+- . `N 3" Installer's Name Address,and Tel.No?_iv_ @-� �1" Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Abe Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 1 f Application Approved by Date ZZ Application Disapproved by Date for the following reasons Permit No. (0 Date Issued rn � No. fl 1 ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: tyX2 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Misposal *pstem .(onstruttion 3permit Application for a Permit to Construct( ) Repair( )"Upgrade( ) Abandon(� ❑Complete System ❑Individual Components Location Address or Lot No. C<J e-37- �� � �3 Owner's Name,Address,and Tel.No.`Brr-�..� Assessor's Map/Parcel O'n,3 os �� � �� CSC F= Installer's Name,Address,and Tel. -Designer's Name,Address,and Tel.No. e- Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date' Title Size of Septic Tank Type of S.A.S. Description of Soil ., Nature of Repairs or Alterations(Answer when applicable) ,,Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 3 / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 1-�).C) "O Date Issued g-/ ------------ -- - ,.- — - _ _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the�On ---site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(X �r ,.c ti :-- at ( 4� _ �� has been constructed in accordance with the provisions ofTitle 5 and the for Disposal System Construction Permit No.— G f-,D&-dated A� Installer ��G - Designer #bedrooms Approved design floyv gpd The issuance of this ermit hall not be construed as a guarantee that the system will n ti!n as desig/ed. Date �� a�rs �� Inspector l VI,J - =--- ---------- -_-- - ._._. . ---------------- - -- -------- No. C� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION,-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(Ll System located at ` � C�z°� r �,—t�iA and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be c mpleted within three years of the date of this ermit. Date �� Approved by 'x, Commonwealth of Massachusetts W Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address Kelly Dohn l Owner Owner's Name t information is Osterville MA 02655 February 21, 2011 3 required for ry every page. Cityfrown State Zip Code Date of Inspection ' Inspection results must be-submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General ,I.nformation...._.__ . forms on the " computer,use 1. Inspector: only the tab key II to move your Patrick M. O'Connell use the return cursor- not Name of Inspector key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address - Marstons Mills MA , 02648 _ Cityrrown State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B. Certification 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: i ® Passes ❑ Conditionally Passes ❑ Fails i ❑ Needs'Further Evaluation: by the Local Approving Authority ✓� February 21, 2011 Job# 11-18 _ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or', has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the l report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and 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•09108 Title 5 Official Inspection Form.Subsurface Sewage Dis sal System•P$ge t of VY �J . a Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address Kelly Dohn Owner Owner's Name information is required for Osteryille MA 02655 February 21, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D i A) System Passes: i i ® 1 have not found any information which indicates that any of the failure criteria described In '10 CMR 15 303 310.C'Mg '5 304 ex ^ y failu;c criteria not evaluated are J V 1 \ l./.JvJ-Cr"i'l l V i'�l.J exist. 7'll'I indicated below. i Comments: i i i Tank is not in need of pumping at this time, leaching pit showed no signs of surcharge or hydraulic failure. i I ( B) System Conditionally Passes: i ❑ 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 I 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 approvedby 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): i i I I E i l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w� 183 West Street Property Address I` Kelly Dohn Owner Owner's Name information is required for Osterville MA 02655 February 21, 2011 every page. City/Town State Zip Code Date of Inspection I B. Certification (cont.) 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): I ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ! ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 1 i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): j i I — I r i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): i ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): r ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I i I I a 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 heallth, 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 r' t5ins•09108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 w 183 West Street i Property Address ! Kelly Dohn 1 Owner Owner's Name information is required for Osterville MA 02655 February 21, 2011 1 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is withi 1 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. I ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or I more from a private water supply well**. Method used to determine distance: I i ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to o'r 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: i . t — . I I i fI D) System Failure Criteria Applicable to All Systems: i You must indicate "Yes" or"No" to each of the following for all inspections: i Yes No j i ❑ ® 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 watt rs due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded ded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 183 West Street Property Address i Kelly Dohn Owner Owner's Name information is Osterville MA 02655 February 21, 2011 1 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: I ❑ ® 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 supplylIor tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. I ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. f ❑ ® 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. (Tlhis system passes if the well water analysis, performed at a DEP certified 1, laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprh, , 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. j ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. Thl e! 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 E I ❑ . ❑ the system is within 400 feet of a surface drinking water supply j ❑ ❑ 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 I If you have answered "yes" to any question in Section E the system is considered a significant threalt, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 - I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i ;M 183 West Street I Property Address Kelly Dohn Owner Owner's Name information is Osterville MA 02655 February 21, 2011 required for ry every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? i ❑ ® 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 El ® 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? I I ® ❑ Were all system components, excluding the SAS, located on site? j ® ❑ 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 syste I s? 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 i Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 1 _ . i i II i 1 I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street i Property Address Kelly Dohn Owner Owner's Name information is 21, 2011 required for Osterville MA 02655 February } every page. CitylTown State Zip Code Date of Inspection D. System Information Description: l I; 1 Number of current residents: 0 — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 01 No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d N/A Irrigation . 9 ( Y 9 (gP )) system. _ Detail: _ I Sump pump? ❑ Yes ZI No i Last date of occupancy: UnknownDate {� Commercial/Industrial Flow Conditions: • I Type of Establishment: i 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 i Industrial waste holding tank present? ❑ Yes ❑j No f Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑! No i Water meter readings, if available: i I t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pagei7 of 17 t i { t I Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address i Kelly Dohn Owner Owner's Name information is ry Osterville MA 02655 February 21, 2011 required for _ � every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) i Last date of occupancy/use: Date Other(describe below): i I I i General Information ' Pumping Records: Source of information: Tank pumped over 5 years ago. Was system pumped as part of the inspection? ❑ Yes ® No� If yes, volume pumped: — gallons How was quantity pumped determined? Reason for pumping: Type of System: j 1 ® Septic tank, distribution box, soil absorption system I ❑ Single cesspool {� I ❑ Overflow cesspool ❑ Privy I ❑ 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 i ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 4 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i I' Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 183 West Street i Property Address Kelly Dohn f Owner Owner's Name information is required for ry Osterville MA 02655 Februa 21, 2011 i every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Approximate age of all components, date installed (if known) and source of information: Unknown i Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ® 40 PVC El cast iron El other(explain): Distance from private water supply well or suction line: feet ' Comments(on condition of joints, venting, evidence of leakage, etc.): 1 ' i I Septic Tank (locate on site plan): 2' I Depth below grade: feet " _ I Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: i — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ INo Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2" l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17_ I I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j 183 West Street i Property Address } Kelly Dohn Owner Owner's Name i information is required for Osterville MA 02655 February 21, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 i I Scum thickness Distance from top of scum to top of outlet tee or baffle 6 i Distance from bottom of scum to bottom of outlet tee or baffle 1Y # How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet_tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees were intact and clear. -- I Grease Trap (locate on site plan): I I t J Depth below grade: feet Material of construction: ❑ concrete i❑ metal El fiberglass ❑ polyethylene ❑ other(explain): I — I Dimensions: f — Scum thickness — Distance from top of scum to top of outlet tee or baffle — i I Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: — Date l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address Kelly Dohn Owner Owner's Name information is Osterville MA 02655 February 21, 2011 required for ry every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I I I I I- Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site Ian p :) 1 Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(ex I lain): i Dimensions: Capacity: ! gallons Design Flow: i gallons per day l i Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No } r Date of last pumping: Date i Comments (condition of alarm and float switches, etc.): j f I i i i • I i *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ IN o i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1;1 of 17 i I i 7 i Commonwealth of Massachusetts f . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 183 West Street ! Property Address Kelly Dohn Owner Owner's Name information is required for Osterville MA_ _ 02655 February 21, 2011 1 every page. CityfTown State Zip Code Date of Inspection I D. System Information (cont.) . i Distribution Box (if present must be opened) (locate on site plan): 0, 1 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryoverjany evidence of leakage into or out of box, etc.): No solids or high stains present, liquid level was found at bottom of outlet pipe. 1 I i I { �44 I Pump Chamber(locate on site plan): C Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I k l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1J2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address Kelly Dohn Owner Owners Name information is Osterville MA 02655 February 21 2011 required for ry every page. Cityrrown State _ Zip Code Date of Inspection D. System Information (cont.) Type: { i ® t.leaching pits number: One 6x6 p� ❑ leaching chambers number: i ❑ leaching galleries number: i ❑ leaching trenches number, length: t ❑ leaching fields number, dimensions: fi ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit showed no signs of surcharge or hydraulic failure. Pit was not excavated due to excessive depth. - j 1 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 { — i Depth of scum layer — I Dimensions of cesspool — 7i t Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No I t5ins-09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 13 of 17 I i { { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 183 West Street Property Address Kelly Dohn Owner Owner's Name information is Osteryille MA 02655 February 21, 2011 required for ry every page. Cityfrown 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.): i i i i i{{ I Privy (locate on site plan).- Materials of construction: Dimensions j Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i E � I i I I I i i { I i I I I t, I I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page i14 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form Not for Voluntary Assessments 183 West Street Property Address { Kelly Dohn Owner Owner's Name ------------._.... _.._.._.._..----------------------------- information is MA 02655 ill OsterveFebruary required for _— _ —_—_ 21, 2011 i every page. Cityfrown State Zip Code Date of Inspection t 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.- i ❑ hand-sketch in the area below ❑ drawing attached separately . i t • i 32 51 1 l. 63 71 a t 4�s'1 J i 1 f West Street r t, i i i Commonwealth of Massachusetts Title 5 Official Inspection Form = p �Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street M I Property Address Kelly Dohn Owner Owner's Name information is Osterville MA 02655 February 21 2011 required for rY every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ®. Shallow wells Estimated depth to high ground water: 20+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: USGS topo map and town GIS. You must describe how you established the high.ground water elevation: Town groundwater contour map shows water below el. 5 and topo map shows property at el.30. I i i Before filing this Inspection Report, please see-Report Completeness Checklist on next pa I Ige. l5ins•09/00 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page!1E of 17 1 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address Kelly Dohn Owner Owner's Name information is Osteryille MA 02655 February 21, 2011 required for ry every page. CitylTown 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 1 ® System Information— Estimated depth to high groundwater i F ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ` I it i t i I i I r . i I I t i I • i i i i i i i 1 i F i i i j I i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 7 of 17 t i i -01 C1 Commonwealth of Massachusetts % co Title 5 Official Inspection Form �� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .y' 183 West Street Property Address — —_--- Alan Botsford Owner O -- '' wner's Name 4,gy information is g�Jh3�^+��,,�� ,�,��; required for every Osteryille _ MA 02655 July 7, 2015 page. City/Town State Zip Code Date of Inspection 'off 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. filling out f:When A. General Information �j filling out forms // ®V / on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return key. Name of Inspector Ready Rooter Excavating 4:1 Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip Code 508-888-6055 _ S112843 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 July 8, 2_015 _ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. V S 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 183 West Street - ---------- Property Address —------------ ------ —-- ------— Alan Botsford Owner Owner's Name information is required for every Osterville MA 02655 July 7, 2015 page. CityfTown 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 pis 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 placed with a complying septic tank as approved by the Board of Health. / *A metal septic tank will pas/s/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. I ❑ Y ❑ N /'F ❑ ND (Explain below). i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 West Street Property Address Alan Botsford Owner Owner's Name information is Osterville MA 02655 Jul 7, 2015 required for every _ Y 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 bro n, settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is levele or replaced ❑ Y ❑ N ❑ ND (Explain below): -7 ❑ 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 6 N ❑ ND (Explain below): t C) Further Evaluation is Required b tl�e Board of Health: ❑ Conditions exist which require furt�Lr 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 Forth: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 183 West Street _ Property Address — ------ --- Alan Botsford Owner Owner's Name information is required for every Osterville MA 02655 July 7, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SA within a Zone 1 of a public water supply. El The system has aseptic tank and SAS and th AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the/SAAS 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 anal y is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the �esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of er 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 ❑ M Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 183 West Street _ Property Address ---- ------ -- Alan Botsford Owner Owner's Name information is required for every Osterville _ MA 02655 July 7, 2015 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 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 40 /feetoa surface drinking water supply ❑ ❑ the system is withi 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is to ted in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) r a mapped Zone II of a public water supply well If you have answered "yes" to aryy 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 183 West Street Property Address -------- ---- --------- -- — -- Alan Botsford Owner Owner's Name information is Osterville MA 02655 Jul 7, 2015 required for every y 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? ® 0 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 560 GPD 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 183 West Street Property Address Alan Botsford Owner Owner's Name information is required for every Osteryille MA 02655 July 7, 2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No 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)): 2013= 218 GPD* 2014= 236 GPD Detail: `High water use during summer months due to irrigation. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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., c.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ? ❑ Yes ❑ No Non-sanitary waste discharged o the Title 5 system? ❑ Yes ❑ No Water meter readings, if av aiiable: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M _ ,•'`r 183 West Street Property Address Alan Botsford Owner Owner's Name information is Osterville MA 02655 Jul 7, 2015 required for every _ Y 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: No previous records found Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500gallons How was quantity pumped determined? Site tube on truck 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•3113 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 183 West Street Property Address Alan Botsford Owner Owner's Name information is Osterville required for every MA 02655 July 7, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 05/14/1986. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'10"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/afeet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 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: 10'6"X 5'X 5.5' 1500 gallons Sludge depth: 6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 183 West Street Property Address --- Alan Botsford Owner Owner's Name information is required for every Osteryille MA 02655 July 7, 2015 page. Cityfrown 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 28 Scum thickness 6" at inlet, 3" at outlet Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Two inlet and one outlet, PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6" j rade. Tank was pumped and cleaned after inspection by Ready Rooter, Inc. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ berglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum top of outlet tee or baffle Distance from bottom of'scum to bottom of outlet tee or baffle - Date of last pumping: Date l5ins•3113 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 183 West Street Property Address ---------------------- --------------- ----- Alan Botsford Owner Owner's Name information is required for every Osterville MA 02655 July 7, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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): 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 183 West Street Property Address --------- --------------- — ---------- - — Alan Botsford Owner Owner's Name information is Osterville MA 02655 Jul 7, 2015 required for every _ y 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet,one outlet. 5' below grade. 2"thick X 20"L x 12"W. Very light solids carryover. No sign of leakage. Riser brings 20" Polyloc cover 4" below grade. Secured w/3, 5/16 hex screws. Pump Chamber(locate on site plan): Pumps in working order: / ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump c/ber, dition 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM •'`F 183 West Street Property Address -- Alan Botsford Owner Owner's Name information is Osterville MA 02655 Jul 7, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'x6'w/4' of stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to inspect and locate leach pit, 6' below grade. Liquid level 3.5+' below invert. High water staining 2" above current level. Clean stone visible through sidewall. No sign of past hydrailic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 .' 183 West Street Property Address -- Alan Botsford Owner Owner's Name information is required for every Osterville MA 02655 _ July 7, 2015 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.)-. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, sign of hydraulic failure, level of ponding, condition of vegetation, etc.): (Sins•3113 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 °M 183 West Street _ Property Address ----- Alan Botsford Owner Owner's Name information is required for every Osterville MA 02655 July 7, 2015 page. CltyrFown 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 I � 3 .1O 01 -It--------------- I 1 v' { O.-+ SC) f I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 183 West Street _ Property Address — -- -------- ----------------- — Alan Botsford Owner Owner's Name information is required for every Osterville _ _ MA 02655 July 7, 2015 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: '5 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. 03/14/1986 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: maps.m assg is.state.ma.us/oliver.ph p You must describe how you established the high ground water elevation: Test hole in 1986 found adjusted ground water at elv= 77.5. Base of leach pit at elv= 87 per engineered plans. Accessed local ground water contours and topo mapping. No high ground water in area of system. 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 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 183 West Street Property Address -- -- Alan Botsford Owner Owner's Name __ information is required for every Osterville MA 02655 July 7, 2015 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 11Z z Z MAP PARCEL O LOT DATE_7/27/04___ PROPERTY ADDRESS:_18_3_—LeA-t_S-L—_—�__ Oast e2vi-e-ee, Ala. 02655 On the above date, the septic system at the above address was Inspected. This system consists of the following: RECEIVED 1. 1-1000 gaiion eE/2tic tank. 2. 1-dizta.igut ion kox AUG 2 7 2004 t 3. 1-1000 ga eion eea ching 12 it. Based on inspection, I certify the following conditions: TOWN OUN DEPT. 4. 7hi-s .iz a tit ee Pive he/2t is zyztem. (78code) 5. 7he zeptic zyetem iz .in pao/2e2 wo2k.ing oade/t at the /zaezent time. SIGNATUREL� - - Address:--Box 66 Cente2v_.�.QLe�l7 ,! 2632 Phone: (508) 775-3338 ------------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped .& installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 - 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE*OF EIVfR©NM' NTAL AFFAIRS a DEPARTMENT OFNVIQN1ViN�`AI��ROTCTION TITLE 5 OFFICIAL INSPECTION FORM—.NQT-:FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION. Property Address:'. 183 O� .Pr...Y;.l l.P. MA •OZ55 . Owner's Name: Del Dauer { Owner's Address: unY nctorvillo MT n7�CA Date of inspection: Name of inspector: (please print) Company Ni / (�acom8e�t, & .SAn lhc. Mailing.Address: LO8 e� � E; Qbb. 02632 Telephone Number: 5 77 :3 3 3 CERTIFICATION STATEMENT y I certify that I have personally inspected thehe twine ofagetthe inspection.aThelinspection was performed based on my s address and that,the.1fiformation reported below is true;accurate and complete as o training and experience in the proper fiinction and maintenance of on.�ite sewage disposal systems.I am a DEP approved system inspector pursuant to Section.1�5:340.of'Fitle 5(310 CMR 15:000). The system: Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority Fails Inspectolr's Signai<ure: Dater —0 shall submit a copy of this s inspector is inspection report�to the.Apptoving Authority.(Board of Health or The system Pqm or has a design 000 DEP)within 30 days of completing this inspection,If hall submi the.r port o thee system n appropriate regional,office of the gpd or greater,the inspector and the system o DEP.The original should be sent to•1th0 system owner and copies sent to the buyer,if applicable,and the approving. authority. Notes and Comments ****This report only describes.conditions at the time of inspectidir and under theunde conditions same or different ^ time.This inspection does not address how the system will perform in the future . conditions of use. naee 1 _ Page 2 of 11 OFFICIAL INSPECTION:FORM—NOT FOkR.VULZJNTAR� ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM � PART A CERTIFICATION (continued) Property Address: 183 West Street Owner: Del: aatter_ Date of Inspection: 1 4 2 7 4 0 4 Inspection Summary: Chekk 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 1� 304 exist. Any failure criteria not evaluated are indicated below. Commen : ��" (-C� r OrAer �.'T ?rvusuif a B. System Conditionally Passes: One or more system components..as described in.the"Conditiona&Pass":section need to be replaced:or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,.will pass. Answer yes,no or not.determined(Y,N,ND)in the J]L 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).isstructurally unsound,exhibits substantiaioinfiltration or exfiltration.or tank failure is-imminent. System will pass inspection.if:the existing tank is replaced with'a complying septic tank.as p.prvved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less.than 20 years old is available. ND explain- NO Observation of sewage backup or break out or high static water level in the.distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection.if(with approval of Board of Health): broken.pipe(s)are replaced. obstruction is removed distrilitition box is leveled or.replaced ND explain: �0 The system required pumping.more than 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: .2, Page 3 of I I OFFICIAL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTIiONFORM PART:A , CERTIFICATION(coritinued) Property Address: 183 West Street 0c;t-Prvi 1 1 e Owner:. T)P1 nailer Date of Inspection: 7/2 7 10 4 C. Further Evaluation-is Required by the Board of Health: Conditions.exist which require f uther,evaluation..by.the Board.of;Health;in order.to:deterniine ifthe system is failing to protect pub.lic•health,,safety or the environment. 1. System will pass unless Board of Health determines:in soordance with 310.CMR 15.303(1)(b)that the system is not functioning in.a manper;which.:Will-protect public health,safety-and the4nvironment: Cesspool or privy is within 50 feet of azurface water )_b Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health(and Public Water Supplier,`if any)determines:that the system is functioning in a mariner 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. DO The system has a.s.eptic tank and SAS and the,rSAS is!within a Zone 1 of a-public water.,supply. rb The system has a septic tank and.SAS andthe 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..bitt 50 feet or;rtiore frog a private water supply well". Method used to determine distance- **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and .the presence,of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure.criteria are triggered.'A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) - Property Address: 1 A y e,—i- StrPPt stQrj7i 11e Owner: r)P1 Da»P _ - Date of Inspection: 7 4 227 4 d4 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each of the:followingfor.all:inspections: Yes No _ 7 Backup of sewage.into facility.or system component due to overloaded or clogged SAS or cesspool 7 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 —'/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped w _ Any portion of the SAS;cesspool or privy is below high ground water elevation. Aoy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: _ Any port-ion.of a cesspool or privy is within a,Zone 1 of a:public well. - _ Any portion of a cesspool or privy is within.50 feet of a private water supply well. - Any portion of a cesspool or-privy is less than 100 feet but greater..than 50 feet from a private water supply well with no acceptable water quality analysis. [This system..passes if the well water analysis,' performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution;,from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are-triggered.A•copy of the analysis must be attached to this form..] WO (Yes/No)The system fails.I have determined that one or..more,of the:above failure-criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner.should contact the Board of . . Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the.system must.serve.a facility with i design flow of 1.01000 gpd to 15,000. gpd• .. You must indicate either"yes"or"no"to'each of the following: (The following criteria apply to large systems in.addition to the criteria above) ` yes nu the system is within 400 feet of a surface drinking water supply` the system is within 200 feet of a tributary to a surface drinking water supply { _ the system is located'in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply-well` If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or.failed under Section D sha11 upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 _ ; Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS �ItSURFACE SEWAGE,DISPOSA1''J`SYSTEM INSPECTION FORM PART B CIiECKLIST Property Address:-1 83 West- street Owner: rlcl raper Date of Inspection:;4 - Check if the following have been done You must indicate"yes"or"no"as-to each of the following: Yes Np 1 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? — — , _ _J 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 tote 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? f different from owner)provided with information on the proper Was the facility owner(and occupants i maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site.has been determined based on: Yes no Existing information:For example,a plan at the Board of.Health.. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance .. is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL)(NSPF,CTION;FORM'-NOT•FOR VOLUNTARY ASSESSMENTS SiJBSURFACE SUW AGE OISPOSALYSYSTUM,INSPECTION FORM PART.0 SYSTEM INFORMATION Property Address: 183 West Street Osterville Owner: Del• Daue Date of Inspection: . 7/2 7 Q4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_; °Number of bedrooms(actual): DESIGN`.flow based on'31.0 15.203 (for example:'1 I0 gpd x#of bedrooriis): " � �J rT✓ Number of current residents: Droesresidence have a garbage grinder(yes or no):M Is laundry on a separate sewage.system(yes or.no):,0Q [if yes separate inspe.;tion required] , Laundry system inspected(yes or no): Seasonal use:(yes or no): Q�g` Water meter readings,if available(last 2 years usage(gpd))-.2 5�;� Sump pum (yes or no):d� Last date o�occupancy:. COMMERCIAL U TRIAL Type of estalz nt: �. :. Design flow. �'',��on 310 CMR 15.203):. Kpd Basis.of dWj0qIow(seats/persons/sgR,etc.): !� Grease trap�present(yes or no):LIL Industrial waste holding tank present.(yes or no): Non-sanitary waste discharged to the,^Title 5 system.(yes or no):'� Water..meter readings,if available:'Y 1 Lase date of occupancy/use: . OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):— If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for.pumping: TYPE OY SYSTEM _Septic tank,distribution box,soil absorption system . /1O Single cesspool - N Overflow cesspool Vw Privy " Shared system{yes or no)(if yes,attach previous inspection records,if any) Ao Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be Qbtained from system owner) —Tight tank. M Attach a.copy of the DEP.approval 00 Other(describe): Approximate me of all components,date installed(if known)and source of information: '1116 Were sewage odors detected when arriving at the site(yes or no):1�0 6 - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 R3 West. Street 0steryj-J 1.2 Owner:_ Del Dauer Date of Inspection:-a 7 04 BUILDING SEWER(locate on site plan)' Depth below grade: _ Materials of construction:_cast iron X 40 PVC`x other(explain): Distance from private water-supply well or suction line: 10 t Comment(oAn'cond�ition of joints,venting,evidence of leakage,etc.): Oj SEPTIC TANK:V (locate on site plan) Depth below grade: . Vt Material of construction: concrete_metal fiberglass_polyethylene _other(explain) If tank is-metal list.age: l3 Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) ,, r -- Dimensions: (if k)r7A x �f 6+� )J uk �'j e� Lo� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 46 ._ 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-. 5 r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte + as related to outlet invem evidence of leakage,etc.): testy,liquid levels �- ®ut T GREASE TRAP&(locate on site plan) Depth below grade.: Material of construction:Anconcrete metalfiberglasspolyethylene(other 3 (explain): Dimensions: VlqA 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: g Date of last pumping: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) T41a S Tnonantinn Timm r,11 V)Ann Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 9' SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 183 Wt-at Stre t Owner • (3si=ewe Date of Ibspec ion: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: r I (I Material of construction: concrete lit metal fiberglass VA polyethylene�A—other(explain): Dimensions: Capacity: f Lfli _gallons Design Flow: _gallons/day Alarm present(yes or no): Alarm level: Aarm'in working order(yes or no):JL� Date of last pumping; , Comments(condition of ai.arm and float switches, etc. DISTRIBUTION BOX: I (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): , t't,p Q�-�vQ O ( Qt� F3(�t" o t1 t t ' •1 PUMP CHAMBER: f1 (locate on site.plan) Pumps in working order(yes or no):)iL Alarms in working order(yes or no):V1 Comments(note condition of pump cham er,condition of pumps and appurtenances, etc.); g Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I.NSPECT.ION FORM PART C SYSTEM INFORMATION(continued). Property Address: 1 Q r�Test�� �t Owner:. fttteT— Date of Inspection: —;,-�7-�-8 4 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number- leaching chambers,number: ljo leaching galleries,number: leaching trenches,number,length: dam- leaching fields,number,dime sions: . &0_overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs.of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) 5 ILonv/ CESSPOOLS:,LD-(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- In *inow dication of groundwate (yes or no): Comments(note ondition of s :il,sign of hydraulic f 'lure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Y.9, Dimensions: nA Depth of solids: ® � Comments(note condition of soil,si s of hydrauli failure)level of ponding,,condition of vegetation,etc.): .9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART C: SYSTEM INFORMATION(continued) Property Address- i R2 rags} ctroct Owner: Date of Inspection: Z2:7 E) SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or . benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. o, b 1U • • T,f P . ' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 183 West Street u Osterville owner: D 1 Dauer Date of Inspection: 712/0 4 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: ,(.,,Ag,-, �, You must describe how you established the hi h ground water elevation: Se y5 t9 -0000 0 J0.y1 l ' 1 tea, Lt a- / f Tifla S Tnenartinn Fnrm�/1 lq/7nnn 11 >•rrnr+rnl•rvr,n-arve:arrnn�rrTrtrtssrrrs:m:•trrtrasrt•.�11+n nTrR�rra�ri�7mA 11'OWN OF WARD OF HEALTH SUDSUIIFACE SEWAGE DISPOSAL SYSTE INSPECTION FORM - PART D •- CERTIFICATION .•••T:'1�T•:'•::ice T.117•:�T:R!•II'iT;TSfT31r.•lTSTF rrr•tlrl-r-a•1 Tilt{'R"f SniTR 11'10. Cog!' To� sem..•mr.�lrnp^lsrrnrnrt•.•n.•rr•r.•-lr•-r•� -TYPE OR PRINT CLEARLY PROPERTY INSPECTED STREET ADDRESS 183 West Strept� nGt 111 NA 07655 ASSESSORS MAP , IIh,O,CK AND PARCEL OWNER' s NAME Drel s=m== I PART D CERTIFICATION NAME OF INSPECTOR Bruce Macallister - - COMPANY NAME Joseph P Macomber & 1" n Inc COMPANY ADDRESS Box 66 Centervi11P,, MA n 632 Street ,Town or City State LIP COMPANY TELEPHONE ( 508 775 3338 FAX ( 508,E 790 1578 R ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposazl system at this address and that t}ie information reported is true , accurate, and omplete as of the time of .,inspection . The inspection was performed and any recommendations regarding upgrade ,, maintenance , and repair are consistent with my 'training and experience in the proper function and maintenance of on-- site sewage disposal systems - Check one; System PASSED The inspection which I have conducted has not found any information which indicates that. the system fails to adequately protect public health or the enviroment as defined in 310 CMR. 15 . 303 ► Any failure criteria., not evaluated are as Stated in the FAILURE CRITERIA section of this, form . System FAILED* The inspection which I have con trcted has found that the system fails to Protect the public health and the environment in accordance with Title 6 , 310 CMR 15 . 303 , and as specifically noted on PART,C -FAILURE CRITERIA of this inspection form. Inspector Signatur Date ..._.>�-tea:.-=—�:�---T+�=--�-_�• copy of this certification must -be provided to the OWNER, the BUYER One where applicable ) and the BOARD OF HEALTH. * It the inspection FAILED, the owner or operator shell upgrade the system. within o'ne year of the date of the inspection, unless allowed or required otherwise as provided in 3.Jo CMR 15 . 105 . partd .doc , lftC � 1ON SEWAGE PERMIT NO. 0s�s I NaTALLER'S NAME A ADDRESS 't)cvaj,0Pln6W-r co". li 9 UILDE R OR OWNER -INq Q &—mv i(.i:51' DATE PERMIT MVEU � UAt E Ct MPLIANCE ISSUED ��t �l !e < a: ASSESSORS MAP NO: 'No. PARCEL NO.- �- g6�g3, Fs$....4 ............ THE COMMONWEALTH OF MASSACHUSETTS j BOARD OF HEALTH �_& �................OF...-..../-,-;�7- ` 1L6-j -`-c.--....-_....-------........... Nppliration for Dhipiial lVork,6 Tonitrurtion rantit Application is hereby made for a Permit to Construct (y or Repair ( ) an Individual Sewage Disposal System at: ....:. -... ®. �-...57.......�!S. wj)-:��.... ............•••--•-------•----'------.....-- ....._..............-------.....------••--.--...--- Locati Address r Lot No. ....1.. ....... ,�.-. !. .........L..IuA- --------------- --- �__... ��1�. .. r.................. r�; ner 77J ZAddress �P.... _- � !'9:�-•---c4qqp=---.... ---�'-a-..... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms____________ _ __ ___________________Expansion Attic ( ) Garbage Grinder Other—Type of Building ............................ No. of persons____________________________ Showers — Cafeteria Otherfixtures -------------------------•--------____-----•-•----------••-•------------- Design Flow..............Y/O............... ___gallons per person per day. Total daily flow_.__.__.............__...______..gallons. W. . WSeptic Tank—Liquid capacity _______gallons Length................ Width................ Diameter................ Depth .___________.. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___._..__�-...... Diameter..........6..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b -_.__ 14:_4 sJ .................................. Date...31rn1 ................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------•----------------------•.._......----.....----------------•-•--•---------------------_....=........................................................ Description of Soil.......rl►'► ? -----------_5Z-1�,�zj................_.............................................................................................................. x w Nature of Repairs or Alterations—Answer when applicable..... L:------- ------- ..... 1791 -•--- . 'I-........PIT-..-•-- "`��!�-.S i-�c!�:�-•--•-•-------------•-----------------------------------------------------------------------.....-•-•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee by board of health. Sign d_ ..... . ....... .••-•••----............................... l/ �..... _._. f� Da e Application Approved By......... ......`�---_---- .......... •-•-•-- i�at 6 Date Application Disapproved for the followin easons_____________________________________________________________________________•__•.__-_-__-_------....•...-....._ ..............•---------.....----..._......-------------•---••--•----------•--•----------- Date PermitNo......................................................... Issued....................................................... Date No.._..................f3 Fss.......................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... .........................OF........................................ AVVIkation for Biiipiiai Works Tonotrnrtion rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....JEZ .-.- 'rcation..57'....--- � V.1r.••. ......................................................... -Address or Lot No..................... Lo .........-------- -- ._.. .............. ......................... ....-•----...-.._......---....------------ O ner --Address ft ---- . ..----•-•-----............................. ........-----....---........--•--............. Installer Address UType of Building Size Lot............................Sq. feet I--I Dwelling—No. of Bedrooms............ .......................Expansion Attic ( ) Garbage Grinder ( ) � Other—Type T e of Building persons.,............................ Showers � YP g ------------=-------•- No. of P=---• ( ) — Cafeteria ( ) dOther fixtures .............•--•---•-•-•-••----------•---------•--......--•--•-------•-••------•----•-•-----•------.....-----•----.....----•-...-•-•-•.............. w Design Flow...............d/0....................gallons per person per day. Total daily flow..........330..._......................gallons. WSeptic Tank—Liquid capacity. .gallons Length................:Width................ Diameter................ Dept h................ 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 ( ) Dosing tank ( ) aPercolation Test Results Performed by.....4&_____________'�.At...................................... Date...3�!R _.:..._.____._.. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ---•------------------------------•--•-----•----.........------.....----............--------.........----••-------•----........---•••-•--•--•--•----------•- C) Description of Soil..........................................................................•---•--------------•--•--•---•-----------•-------.......--•---•--------•--....._......••--••-- x U ........••--•------•---....•---••--•--••...............•--•----•-------•---•...---•-...---......------••••------•--••--•--•...••----......-••-----••----.....-•----------......--•.......------•-------- w U Nature of Repairs or Alterations—Answer when applicable.......:.......................♦ti.0.0............_.-74 -..................... -------------.0-0-----(0 i �1T.....------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance:has been issued by the board of health. Signd......................................... �• Da Application Approved By............................ ...... _.. ..... U ` 6 Da e Application Disapproved for the followin r asons-.............................................................................................................. .......--••--......-•-•--•--••-------•..............................•--•--------••----..........----...--I•••-------•••-•••-••-•-....•-••---•---•-•••--•----•---•-----•-••-•----•---•---•••.............. Date PermitNo....................................-.................._ _ Issued._...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF............ ............................................................................... Trrtifiratr of Tomplittnrr THIS IS TO CERTIFY, That the I �vidu I Sewage Disposal System constructed ( ) or Repaired by..._... -----• •-•• -...••-- -----------------------------------------••--•....•---�. ` y ?� �er at....•---•--•••....._-••-•--------•----....... iC Inst ^r Q `-4 e-f v� (', ---------------•----------------------•---......•----...---•--•--...... has.been installAd in accordance with the provisions of TIT F 5 of The State Sanitary Codjs d scribed in the application for Disposal Works Construction Permit No...._. :-_..' .. ..._._._. dated......_S `�: _......:.THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAN EE THAT THEi SYSTEM WIL U ION ATISFACTORY. k W DATE g._ ...------ • ••. ..... .----...---•.... ......... Inspector.............. _._.....................----...--------•-------....-•---•---•----- �3 r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF No..... .'..... F k Elispoottl Works Tonotrnrtion f eruttt Permission is hereby granted................... ........ ........................................................ to Construct ( ) or Repair (,)4 an Individual s Sewage Disposal S g P Y � Street $ as shown on the application for Disposal Works Construction Permit ................ ... Da . .. .. ................. . .:.:.. >. �� 6 B a of Health tilt.DATE. ...... ....................................................... FORM 1255 A. M. SUl_KIN, INC., BOSTON 17LSIGN DATA � : �sWAM 1� L Z` 51 MC-L.E .FA M I Li — 3 f3CD Ro o"S �. _ _ _►oo.o o - -- - WITH GA24AC•E D%SPoSAL. D '^�'13 ���'�`'"" ,air Wow DA I Uy FI>W -- I 1 o * 3 Y. So% ' 49 S G.P, p. 3 � 9 " 4EPTI C mvju L = s-5o x Zoo7 ` 440 G,P. D USE 16700 GAL. TgNJL. 82'r DISPOSAL- P1T - vSE (3) l000 6At_w14� ST60C SIOEWALL AREA s 264 6.F 244 S.F it 2.5, 3 440 0.P. D. . ®oTTBry A TX A I .T4 S,F. 1 r et 15,4 S.r. o TOTAL VESI&O _ 814 GIB, TOTAL. Qq 1 W (=U W fs.P. 0. Dwc u.1 y fr ° 1�ER o Q ZATZ 2 141Q P6-(L 1 Qc4 k P,I" OF M�� �-;/9/✓k I-X7 46.9 �o u4�t q1.1 Ff1ER No. 2,9733 " �G� sc, 0'3 ,�,��J�v� c 9 •\ �� /sTEA tt TOP OP cd 1 1 P.T 1e11 TE`T Ho le P-S"j 31 t_............. .�-�- — ,-A '7 5 4.[J'L .-' ToPo� I-Us, rl �. •,G'V / FG. 9 8 0)/ 1 S��o1l. 1 ID Is 7" "o L.64CN ,� 93.a Box �j3•(" SE>oTiC V ML=D w�rH 4 JAW. JNW. SA►Jp ��, - f2 a87z. '-, sT l d- t1.87,0 SCpt Z t Sv' DATC APi2kL-1 PR o wa ul, ITS FLAtQ RCFl2E►JGct" No SCALE I -0 T . 13 PL.g1C.. I I Z PG-, �9 BAD-TE1Z � >JIJ,E� c. Izc�I srt.=lz.c_p t_nut� sv�.v c�oQ s AAA►.a.v c.��U�: ;:,� �.�I LC•..�W,�-i..�. Gt,L"�A�...( O STL=1�J I LL,E -- Nt A S 5, APPLICANT R0q>GIZT" 't>AVE.R.. ?N 1 S PLAN 15 NOT 13ASC-D o N AN I05MMIrNT �;UWEY A►30 WE OFFSLTS 5W0vVN H eTP-000 sNOULD &Ja- PCZ USG O Ta E5-771 WSy I-oT DES I G-N DATA 5)N&4Z ..FAMILI - 3 13CDR.00MS WITH &A2tuAGE D%SPoSAL_ , 9 T%{3. Wow DAILY FUNq L I1O * 3 Y. $oZ, ' 49S G.P, D. ! ` cs`A s SEPTIC "MvZ4 a 3"5O X 2oo7 a 660 G.P. o USE ISoo GAL. -rA1 JL, $2'± DISPo--%AL. PlT - VSE (3) lOoo 6AL,+4 -,M60 ' SIDEWAU- ARkA 264 5. F.. 264 5.9 A 2.S' s 440 G,P. p. BoTTory A t2.ic A • 194 S.F• % lit 15'4 s.r• x L o TAL VESIGO p To z g14 G:P. ►�, cx►ST�N� A � ti o TOTAL ICAWY FLOW = 49S Cs.P. b. o Dw�u..VFi PER o►J 1ZATE 2 Mw Pt p- ►l)G�I nj `ZN OF o��P 9�9Dy 46.9 PrIER §ULLIVAN q1•) p %w `AY y1•I' ! No. 29133 0 '• I �O,r '/s7�A� 4t� ToPo+ GU ( 1 P,T 11�.° 11 I , ;' TE`,T Flo le P-S'j3I Z_............... �6.- �.. ,,.�_�- CiAy.1L''R•4 ��erSnc. - Tod•-� Iu�c.V,�tly iH(�'Dery�o SN�u...���• 1�-21�,,. "`� ezv.. 94. 2 FG. = 98.5 rt = 94,v't Lo4n4q i/: � - . / c r!t l7I : � ,. �,, ,. J 77T� rr !• 3%TjTJ"%; ,:.'� �000 �� GA 1. //V✓, DBST• �SO INV. rAl $LC-101N 93.0 , 53. , SEP7C a,7- TA,u IL M L=p '� w.TN f ENV. l AJV. sA►J p 3/4to I'�° 9 3.t.. 9 3 9 w�ls�lc� � a87i SToN� ,' t1. a-I.0 'Z 4+-- LoCAT1o0 oGTe�ZVILu:—:- i SA D SCALic. 1"�Sv` DHTC A�iZ.11.`! f�t<i(� a. P R L)1 11.E ' ITS 1V o ScN l.E �N RAC FI' fZtE►JGE" Lo T•, 13,, PL..131L. I I Z PC, (,`J �h�ST 1 C� S cpZl L 3Y yT�M'T�'iS G BA�.TEIZ �. QQ C ZtJ It, 2. I�F�VJITrk' C t,�C#�}..1 RCG ISTL=R.eV lAut� SvfVCYo25 M IL rat... O STUTW I IJUE M A S S APPLICAMT 1Zc)p C ZT" �AVI.iZ W S PLAIN 15 MoT 13ASCD 01,4 AN (IJSTltUMUJT- sk)r-vEY A►JD yAP- o1=F'SG75 5NowA1 HER- ok) 5MovLv &Jar P USIz b- Ta P-�S7Ae"Sq