HomeMy WebLinkAbout0055 WIANNO CIRCLE - Health 55 WIANNO CIRCLE
Osterville
A = 139 '' 023
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Wianno Circle
Property Address
Garvis
Owner Owners Name o'
information is required for OSterville Ma 10-23-14 ?
every page. Cityrrown State Zip Code Date of Inspeabon
CO
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: A. General Information
When filling out
forms on the
Rf-
computer, use 1. Inspector:
only the tab key
to move your Douglas A Brown
cursor-do not Name of Inspector
use the return
key. D.A. Brown Inc
Company Name
P.O Box 145
Company Address
Centerville Ma 02632
� City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
OU 1 LC:ertifi:t- ation
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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10-23-14
Inspectors natu�re � 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.
tsins-3113 Title 5 Official InspectilFar.m. Vrfaweewage Disposal System•Page 1 of 17
commonwealth of Massachusetts
v Title 5 ®f f icial �lnspcction Form
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
55 Wianno Circle
Property Address
Garvis
Owner Owner's Name e.
E 23
information is -' •• •
required for Ostervllle Ma 10= -14
every page. Cityrrown State Zip Code Date of Inspection F
B. Certification (cone) F ti
Inspection Summary: Check'A,B,C,D or E!always complete,all of.Section.D a
A) System Passes: F r• ,, �., , _
® 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: -
.
At time of inspection system met all passing requirements..The system was installed in 1902 and..
according to,real estate broker was only used as a summer/seasonal house:Future performance
under the same or increased use can not be determined from"this report
41
B) System Conditionally Passes: a;l• '
-❑ one or more system components as described in the`'C0 :itional'Pass" section need to be
replaced or repaired. The system, upon completion,ofthe 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 nof'
determined," please explain.
I and over 20 ears old"or the septic tank(whether metal or not)"is
The septic tank is:meta p .
p Y
structurally
't ntial.infiltration or exfiltration or tank failure is imminent. System
i -n unsound, exhibits substantial
'
will pass inspection if the existing tank is replaced with a complying septic tank as app roved by the:
Board of Health.
*A metal,se tic tank will ass inspection if it is sound, not leaking and'if a Certificate of
p
p p .
m liance indicatin that the tank is less than 20 ears old is
ailable.
•Co _
p 9
N Y
, "ND,Ex lain below fi
r- _
t5ins•31`13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page.2 of V.
I
Commonwealth of Massachusetts
Title 5. Official Inspection Form! F
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 wianno Circle
Property Address
Garvis ` f
Owner Owner's Name
information is ill terve
required for OS Ma 10-23-14
every page. City/Town State Zip Code `'. Date of Inspection
B. Certification (coot:) w
❑ Pump Chamber pumps/alarms not operational. System will pa§iwith 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).
El broken pipe(s)are replaced ❑ ❑Y , N'' ❑ ND (Explain below)
❑ , obstruction is removed E [ N E NO(Expiain below)
_ • - y .. �i
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."
F a° 1 System:will pass unless Board of Health determines !Waccordance 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:
El" , Cesspool or,privy is within 50 feet`of asurface 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
55 Wianno Circle
Property Address
Garvis
Owner Owner's Name
information is Osterville Ma `10-23A4
required for
every page. Cityrrown State ,;•Zip'Code Date of Inspection,
B. Certification (cost.)
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: . V
❑. The system has a septic tank and soil absorption system (SAS)and.the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply-
El The system has a septic tank and SAS and the SAS'is within 50 feet of a private water
supply well. +
E] `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 wafer 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:
r
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 ;
*, LL Discharge or ponding of effluent to the surface of Ahe,ground or surface waters
® due to an overloaded or clogged SAS,or cesspool E
,. ..
Static liquid level in the distribution box atjove 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
Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 4 of 17
t5ins•3113 +..
Commonwealth of Massachusetts
n Form ,
Title 5 Official Inspection
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments;
�., 55 Wianno Circle P
Property Address a
Garvis a
Owner Owner's Name
information is r
Osterville
every page. CitylTown -
required for �. State Zip Code 'Date of Inspection .
_ p
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: e
® 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 indicat®s absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to:or less than 5 ppm,
provided that no other failure criteria aretriggered. 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-
El
10,000gpd= - t ,
❑ ®" 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 imust serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. 4
For large systems, you must indicatE Jeither 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 supplyi _
` the system is located in a nitrogen sensitive`area(Interim Wellhead Protection
El
Area—.IWPA)or a mapped Zone 11 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
w system considered.a significant threat under Section E orfailed 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.
{5i0S•3113 Title 5 Official Inspection,Form:Subsurface Sewage Disposal.System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspectibn Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments,
55 Wianno Circle
'Property Address
-Garvis k '
Owner Owners Name
information is OSteNllle Ma 10-23A4 .
required for
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 eowner;occupant.,,or-Boa rd of Health
❑ Were any of the system components pumped oqt in the previous two weeks?
. ; .
Has-the system received normal flows•inthe 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 backup? ,
® ❑ Was the site inspected for.signs of break out? ti
, �,.... as ,. z .'.' ..' ,.., :'• . r. .i+.... y -'fx +': F �+
® ❑ Were all system components, excluding,the SAS located on sites •. .
4 _ 1 .• .. f
' _ ❑ Were the septic tank manholes uncovered, opened, and the`interior,of'the tank
inspected for the condition of thebaffles 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!Systerh(SAS) on the site has
been determined based on:
;x _
Existing information. For example, a:plan at cne.,boara'0r neaiitI. = r
❑ �;® Determined in the field (if any of the failure criteria related to Part C is at Issue
approxirrtation'of distance'is,unacceptable)(31 o CMR 1,5 302(5))
D. System lnformation '.
' Residential Flow Conditionii
s:
4
Number.of bedrooms(design): 1 Number of bedrooms(actual): `
R 440
DESIGN flow based on 310 CMR 15.1203(for example. 110 gpd x#of bedrooms):
tw
t5ins•3113 Title5 OFficiat Inspeclion Form.Subsurface Sewage Disposal System Page 6 of 17 ,*F
Commonwealth of Massachusetts,
Title 5 Official. inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
55 Wianno Circle
Property Address " <
.K .f..
Garvis
Owner Owner's Name
information is INa �,, 10-23=14
required for OSterville
q State Zip Code Date of Inspection.
every page. Cityrrown r
r, r
D. System Information
Description: °. ` , . ' � .�"�� ' r• . .
according,to design plan system consists of a:1500 gallon tank d-boa and 4 flowdiffusers with 4 ft of `
stone
Number of current residents:
. ..: ., ,- y ` _• J`. ` Yes i
Does residence have a garbage grinder? ❑ ❑ No
Is laundry on a separate sewage system?(Include'lawndry system'inspection` ❑ 'Yes f .No"
information in this report,) r,
Laundry system inspected? ❑ Yes ® No'
®"Yes ❑ :.No
Seasonal use?
,.,
Water meter readings, if avaiiable(last 2 years usage(gpd)): r..
Detail:
2012----198 2013--237gpd .system not designed for use With garbage dis osal
"
Sump pump? ' -„ Yes ❑ No
2 seasonala<:
Last date of occupancy: gate
41
CommerciallIndustrial Flow Conditions '
Type of Establishment:
`K
Design flow(based on'310 CMR 15203): s Gallons per day(gpd)_
•Basis of design flow(.seats/persons/sq.ft.,etc.) t
µ . y Greasetrappresent? ❑ Yes ElNo_ 3
3
' ❑•°Yes,Industrial'�waste holding tank.present? x J
<-- j El No,
u w •b' •"t b ... ...
. Yes
N
•
Non-sanitary waste dischargedyto the Title 5 system?
Water meter readings,if available:
f
° Title 5 Official Inspection Form:Subsurface Sewage Disposal!System•Page.7 of 17 =.•
-t5ins 311 T. r - ..
Commonwealth of Massachusetts -
Tide 5 Official Inspection dorm.;
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments'
55 Wianno Circle
Property Address
Garvis
Owner Owner's:Name
information is `.INa 10-23-14 ` +
Osterville
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.).
Last date of occupancy/use: Date
Other(describe below); ,4
'General Information
Pumping Records:
Source of information'
Was system pumped as part of the inspection?' 0'Yes ® No
If yes, volume pumped: s " gallons,
How was quantity pumped deterriined? K'
Reason for pumping:
Type of System: ,
® Septic tank, distribution box, soil absorption system
Single cesspool`
(] Overflow cesspool =
[] N Privy''
Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a'copy of the current operation an
- maintenance'contract(to be obtained from system owner)and a copy of latest
inspection ofthe,l/A system by system operator under contract
,.
Tight ank. Attach a copy of the'DEP approval
Other(describe
); f
... ref° .. _ • .. •y.
t5ins•sna Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
:,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r ,
a 55 Wianno Circle
Property Address
Garvis
Owner Owners Name
information is Osteryille Ma 10 23-14
required for
every page. CityfFown State Zip Code Date of Inspection
D. System Information (cunt.),
Approximate age of all components, date installed(if known)and source of information:
1995 per cert of compliance
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
•
Depth below grade; a teen
Material of construction.
❑cast iron ❑40 PVC : ❑ other(explain): '
x
Distance from private.water supply well or suction line:_ feet r
Comments(on condition'of joints, venting, evidence of leakage, etc.j
cank(loatoo n site pa )SeptoT
225-
= , Depth below.grade: feet {
Material of construction:' '. .
® concrete ❑ metal ❑fiberglass ❑ polyethylene '❑other(explain)
4 {
a.
:= 1f tank Is metal, list age; years
age confirrr►ed by a,Certificate of Compliance?(attach a copy of certificate) 4 ' ❑ 'Ye ❑' No "
1500 gallon
Dimensions:
e -light heaviest at inlet
Sludge depth:
t5ms-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
sm
Commonwealth of Massachusetts
Title 5 Official Inspection ForM t
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 55 Wianno Circle
Property Address _
Garvis
Owner Owner's Name
information is Osterville Ma �10-23-1.4
required for
every 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
light t.
Scum thickness'
Distance from top of scum.to top of outlet tee or baffle
s
Distance from bottom of scum tobottom of outlet tee or baffle
wooden pole
HOW were dimensions determined
Comments.(on pumping recommendations,inlet and outlet tee or baffle condition $tfUCtUral integrity,
liquid levels as related to outlet invert,evidence of leakage, etc)
tank looked ok at time of inspection with.no signs of failure or surcharge.,recommend pumping every
2-3 yrs
Grease'Trap(locate on site plan). a
Depth below grade. f feet
Material of construction:
❑concrete K ❑,metal 0 fiberglass' ❑ polyethylenes other(explain): .:
Dimensions
Scum thickness
Distance ~from top.o `scum o
f to top of utlet tee or.baffle
Distance from bottom of scum to`bottom of outlet tee or;baffle
Date of last pumping; pate
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage.Disposal'System Form-Not for.Voluntary Assessments
M 55 Wianno Circle s
Property Address
Garvin ;
Owner Owners Name ' w
information is OStervllle Ma 10723-14
required for State Zlp Code r Date of,lnspection°,
every page. City/Town 4
D. System Information (cont) w
Comments(on pumping L.recommendations, inlet and outlet tee or baffle condition,'Structural integrity,- "
liquid levels as related to.outletinvert, 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)'
.r jr
Dimensions:
Capacity: gallons,
Design Flow. ° gallons per day ¢`
t. -
Alarm present ` > z :, Yes ❑'No a f" F..
Alarm level-."-. •Alarm in working order.., ❑'`Ye5 g ❑ No
Date of last pumping: 7gate
Comments(condition of alarm and.float switches, etc,):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes El No'
..' - -_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.11 of 17
l5lns 3113.
Commonwealth of Massachusetts,-
!
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
w 55 Wianno Circle
Property Address ,
Garvis
Owner Owners Name
information is required for Osterville Ma r 10-23-14
every page. Cityfrown State Zip Code Date of Inspection.
D. System Information {cont:)
Distribution Box(if present mustbe'opened) (locate on site0.1
plan)
Depth of liquid level above outlet invert ,
Comments-(note if box is lever and distribution to outlets equal.,any evidence of`solids carryover 4any
evidence of leakage into or out of box, etc.): 4
box was level with 2 speed levels recommend installing riser on tank and d-box
t
Pump Chamber(locate on site plan)
Primps in working order ❑ Yes ❑ No*
Alarms in working order: 0 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 Syst66(SAS)`(locate on site plan, excavation not'required)
If SAS"not located, explain why: ;
. sr
measurement for cover was under walkway _ .
4, t5ins 3n3`,^' " ;. 711ie 5 Official InspeWon Form:Subsurface Sewage Disposal System Page 12_'of 17'
Commonwealth off Massachusetts ,
Title 5 official Inspection` for
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 55 Wianno Circle
Property Address
GarviS
. tr
Owner Owner's Name
information is Osterville F Ma 10-23-14
required for State Zip Code Date of Inspecti
every page. City/Town on
i.
D. System`°information (cont.) f
Type:
❑ leaching pits number:
❑;, leaching chambers number:
4,flowdiffusers
® leaching galleries number.
leaching.trenches :3. ,> number, length
leaching fields number,'dimensions. W
t >
overf! wcesspoof number:'
innovative%alternative system
Type/name of technology .
Comments(note condition of soil, signs of hydraulic failure, level of pondmg, damp soil, con dition`of
vegetation,etc.): _
no signs of failure at time of inspection in area'of flowdiffusers `
.. ,� •fit-�'. r,a 'e' ,...; 4 t of
" x
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration x'
Depth—J top of liquid to inlet invert y
4. N
;= Depth of solidslayer. 'ry
Depth of scum.layer : A.
Dimensions of cesspool
Materials of construction
4 indication of groundwater inflow ❑ Yes ❑ ,No
Tdie 5 official inspection Forth:Subsurface Sewage Disposal System Page 13 of 17
>i5ins•311 3.
i
Commonwealth,&Massachusetts
Title 5 Official Insect ®n Forrn
■ f e
Subsurface Sewage.Disposal-System Form-Not for VoluntaAry Assessments
55,Wianno Circle r o s
Property Address a " { °
Garvis �
Owner Owner's Name
information is c �`' '` �,a '" + r -
i 10 23=14 +
required for OSteNllie Ma: * f -,
eve page. City/Town ' State Zip Code Date of lnspection
every ar 1€
D. System'Inf6ftation (cont "
Comments(note condition'-of soil„slgns,of hydraulic failure,°level of..pontlmg, condition of vegetation
• etc.);. n�� °,fi : � �- � r r
r ,:41
3.
; L
V
M_
- ,�'; �,.• - ter' ^
Privy(locate on site plan) x kz r
Materials of construction
Dimensions P + #
Depth of solids m °�
Comments` note condtfion'of soil+st ns`of h draulic failure leuel of .ondtn condition of veg etation
9 Y P , g, <.
etc)`, '
u ,-k 1 ai t '.'✓ Er 1 i.-{` ,( y tA'L TtR A'� i "T fie• tl
7 'a e;
's ` r � c •�� 1 raj � s ° ✓ :�" �" *'
' it
A.
OWi'¢: � -,,# ,fi0. a ,� t� + �✓ Y'fit 3 '. S
t t5ins 3/13 r ." F r Title 5 Official Inspection Form Subsurface Sewage Disposal system 4 Page 14 ofA7
j �..1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form Not for Voluntary Assessments
55 Wianno Circle
Property Address
Garvis
Owner Owner's Name
information is Osterville Ma 10-23-14
required for
every page. Cityrrown 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
t5ins-3113 Title 5 Official Inspection forth: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
55 Wianno Circle
Property Address
Garvis
Owner Owner's Name
information is Osterville Ma 10-23-14
required for
every page. city/town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
no w at time of perc
Estimated depth to high ground water: 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: 10-23-14Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
design Ian
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
l5ins•3113
1
Commonwealth of Massachusetts
__, i I. Title 5 Official Inspection Form
R a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
55 Wianno Circle
Property Address
Garvis
Owner Owner's Name
information is Osterville Ma 10-23-14
required for State Zip Cade Date of Inspection
every page. City/Town
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
t5ins•3113
- •t
Town-of Barnstable
ti
Regulafbry'$ervices {
r MASS`E� Richard Scali, Director
1639. a�w
�pTen � Public Health Division.`
v 'Thom as Mc]Kean;'Director a f
200'Main Street, Hyannis, MA 02601
Office: 508-862-4644 fl: Fax 508-790=6304 `
October 21 2014 ,
Re: 55 Wianno.Circle;.Osterviller
To Whom It May Concern,
He 55 Wia
alth Division,records indicate that the septic system located at imo Circle
,
Osterville was repaired in accordance with the provisions of Title 5 on November.11;
1995.
A variance from Section 15.211(1)•of the State Environmental Code was"required m.`;'
order to place the S.A.S. five(5) feet from the property line in lieu of the$ required ten
(10) feet. The issuance of the certificate of compliance certifies that the variance was
granted.
Sincerely,. "
Thomas A. McKean, R S., CHO
Director of Public Health
Town of Barnstable <x
16
f
+ 1. • - 'Wf' 1 - V.•• V V
.. ... nit:
Page 1 of 1
TOWN OF BA*4STABLE
LOCATION 'K. ; I J l A 4'A/a C i aL SEWAGE#
AGE dr v 1 l ASSESSOR'S MAP&L QT
A,ME&PHONE NO.' o biZ � y 3 a- Q 36
EPTIC TANK CA kl 5 0 _
I:EACHIINKp`FACILITY: (type)' '?7LeN�;M
NO.OF BEDROOMS
,�'� t
BUhLDER OR QWNER J C�C 1-� ,
x r J. rr
PERMITDATE'ZG-.I C7 ITS- COMPLIANCE DATE:'
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom af.heaching Facility:. =" Feet
Private Water:Supply:Weli and IeachingFacility (If any'wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wedand and Leaching Facility(If any wetlands exist } .
within 3W feet of leaching facility) Feet
Furnished by L
le �
5 , ♦ - ref /1 Y�.. + .._k �}
7{.
http //'issgl2/ihtranet/propdata/prebuilf.aspx?mappar=139023&seq=1 " 10/23/2014
FINE 1p Town of Barnstable
O
Regulatory Services
+ BARNSTABLE,
MASS. Richard Scali, Director
1639. ♦0
A,Ep39�a Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
October 21, 2014
Re: 55 Wianno Circle, Osterville
To Whom It May Concern,
Health Division records indicate that the septic system located at 55 Wianno Circle,
Osterville was repaired in accordance with the provisions of Title 5 on November 11,
1995.
A variance from Section 15.211(1) of the State Environmental Code was required in
order to place the S.A.S. five (5) feet from the property line in lieu of the required ten
(10) feet. The issuance of the certificate of compliance certifies that the variance was
granted.
Sincerely,
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable ` .
t f
bye /, TOWN OF BARNSTABLE •
LOCATIOI+- IU0 C- I r2 SEWAGE 3k 5'' P S�
LAGS Q �-relz tJ !I C ez, ASSESSOR'S MAP& LOT
is,34 AXE&PHONE NO [ 0 U12 Co LI 3 a-- 0 5,30
EPTIC TANK CAPACI*
i � QNGh1 " E ;c
LEACHING FACILITY: (type) =e)---��„
NO.OF BEDROOMS
I1 BUILDER OR OWNER 7 C1 C 14
�e
PERMIT DATE: /0-/ " ! COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) Feet
Furnished by
.� � .,, i
�" �, �� /'
�3 � � - � o c � �3� �
�3 ��
� ��
/S�� ���,
,o �� i � � �
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v�
No. FEE 3
THE COMMON/WEALTH OF MASSACHUSETTS
_VA2N��! , MASSACHUSETTS
( ppyfi•attun for Ton$tzncttun 11crutit
Application is hereby made for a Permit to Construct ( ) or Repair(1,�an On-site Sewage Disposal System at:
Locations Add_ so�Lot Owner's Name,Address and Tel.No. -
��W�,� NNo e rz NANCL-/ 00 trl e.
In/ Name,Ad�tess,�,qd Tel.No D ner's Name,Address and Tel.No.
C� G-� l S''3
!�A/zr vl c Si3a�os So I✓wI 7 9`/- la G S
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( �
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow O ,gallons per day. Calculated daily flow y1�• 9 gallons.
Plan Date �9 `d ei S' Number of sheets 2- Revision Date
Title
Description of Soil `G h LCad$_4 S'o i- 1� � SAr,b LG'b Al 2 — Do
A,1eQ I A,,e .So n�Q
Nature of Repairs or Altera (Answer when applicable) �.� h/�C
� �iw ji 5—bw C-6VIJS
1 UwrJ�1'L
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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 Bo rd of Health.
Signed Date `5
Application.Approved by Date /D �S
Application Disapproved for the following reasons
Permit No. Date Issued
4
.+y f , M1• (.r I l./
FEE /
1 THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
' itc�tttIIn fIIr�.�ts IIstt1 gst.era Tunstrurtion jhrmit
Application is hereby made for a Permit to Construct( ) or Repair(�-(an On-site Sewage Disposal System at:
°r Location Addre' or Lot Owner's Name,Address and Tel.No.
1 11A 04/c' e I rz
'ln a7lte Name,Ad ess, nd Tel.No. / De igner's Name,Address and Tel:-No.
7` , s o 1 3 7
'' -7
rr
Ay
Type of Building: L
Dwelling No. of Bedrooms Garbage Grinder( �J
Other Type of Building No_per Persons Showers( ) Cafeteria( )
Other Fixtures `
�/ I.
• Design Flow I.U gallons p dy41' Calculate°d daily flow � �~ gallons.
Plan Date Number of sheets Z" r Re Vision Date,
�• r ltle "in
} N
`. Descri tion df 6oil L CM +/ > _ S.fi rL sa'/ L G y k 1 3 CJ
,r
Nature of Repairs or Alteratio s(Answer when applicable) ,Z ` / vG
�r l r,w � � ��t� SZtx,s t(. j7 / y'GtiS�I1rc /si ar. � 1p.�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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 b this Board of Health.
Signed ~ `' Date
Application'�pproved by JCS/ Date /0
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
' � C►�` � 134 R N S k MASSACHUSETTS
(gPrtifi ate of (gontylianre
THIS IS TO CER TIF_Y,,that the On-site Sewa a Disposal System installed ( )or repaired/replaced V(on ll
by for
at �—` /4 I U A/O C� has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 ` dated
Use of this system is conditioned on compliance with the provisions set forth below: . .
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE ' ! �"✓ Inspect r
'THE COMMONWEALTH OF MASSACHUSETTS J
/�• �'^ 5
12 A fi lv S''�"p y I� , MASSACHUSETTS FEE G
is IIsal stem C nstruj:fiun jhxrait ,.
Permission is hereby granted to 'l G�� C'n
to construct ( ) or repair(./I an On-site Sewage System,located at S 5 b,/M AJ/V n C
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions. .,
All construction m t be mpleted within three years of the date below.
DATE fi u�� Approved by
FORM 1255 Rev.3/95 A.M.SULKIN c6.-BOSTON,MA A, .
Parvin, Lindsay
From: Parvin, Lindsay
Sent: Friday, October 17, 2014 11:37 AM
To: McKean, Thomas
Subject: 55 Wianno Circle
Albert Shultz called regarding 55 Wianno Circle. The 1995 septic plan/permit has a note explaining that a variance was
granted. The leaching is located 5 feet from the property line as opposed to the required 10. They want to be sure that this
variance was in fact granted. I think they are looking for some type of documentation from the Board. Donny said the fact
that the certificate of compliance was issued is documentation enough. Otherwise, it wouldn't have been issued. I looked in
the attic but couldn't find the 1995 Board paperwork. Do you agree with Donny assessment(I do)? Or do you know of
another place I might look for 1995 Board paperwork?
1
C.B.
FND
I
LOT 108
zl
p � o
14 NOAK 12" OAK 106. 78 ,6` OAK : [
eo,
N �: 9h 5 L= VICL
100.E
' 1 p 14" OAK GAR DRI VE
6" OAK 2 � � uj QN
' 18" OAK 0. Y I a � � � Q NO TE.
n
o C)
99.4 � 3 o w VARIANCE REQUIRED FROM SECTION 15.211(1) OF-
o
`' go °' -�- -J THE STATE ENVIRONMENTAL CODE, TITLE 5
'� -
o A ��4 z � 37 + _•„ 96.2 x/s TOWN DISTANCE FROM PROPERTY LINE TO S.A.S.
"� 4" PINE W 9 WATER TO BE 10 FEET REQUIRED, 5 FT PROVIDED.
o ���j �� ' o RELOCAT APPROVAL REQUESTED PER SECTION 15. 405 1 a
o
"
10 PINE O 99.0
O
r 00. jlh 98.j
99. 16` OAk
TWIN
14" OAK
..},� 16" OAK / '� ��J FREL OCA TED
co yay / �P WA TER• MAIN
108. 00 B.M. BASIN
/ F & G EL = 97.27 B.M. TOP OF
ASSUMED BRB EL = 700
C.B. ASSUMED
FND
LOT H6
�1�4NN0 CLRC LT'
4D FT Iy4Y
REV.
cos No 95-565R-00 OA'E' SEPT 21, 1�9,
CLIENT RUCHE SCALE- 1 /N = 20 FT
OR Br R. U'tl. SHEET 1 OF 2
REGISTERED SANITARIAN 14PPR'O VFD.- Bm" OF HXALTx ��� ,� _r s �. " �
R. J 0 Ike a rn t°{4" +}� r , 9 IACATION. LOT 1 O _ IYlANNO
PROFESSIONAL
/ iF -1-
>' RICHARD
LAND SURVEYOR a4TT A Q M TJAMES � �°
35 ROUTE 134, P. 0. BOX 237 �, ,,.. �!��JL�Gi�L_ - �1 L 1 Y %r —�1 �
'�'Z-s O'HEA y .AF1
+ . 2787'1
k* SWAN RIVER PLAZA, UNIT 2 S'u r�e (J�, COY.YBNTS' I�
j '� ,` �, fu�� ago ASSF,SSQf�� MAP 14C� PARCEL 107
SOUTH DENNI.�, 1fA 02660 SE oh_s�QN°✓ FLOOD ZONE.__C-_F,LFVATION.°_�A ,MAP DATE.
r
MAIN
F,yS,T
ALL COVERS TO SANITARY 4' �gNA'O
SCH 40 PVC
UNITS SHALL BE BROUGHT Bq y
PIPE - MlN P/TCH
10 FT. M/N. TO WI THIN 6 INCHES OF q RD�
s -- — FINISH GRADE 118" PER FOOT s�Q �NVE
� TOP OF FOUND
EL- 100.0 I CONCRETE 4" SCH 40 PVC FREcAsr
OWDIFFUSOR
COVER FIRST 2' TO PIPE - MIN PITCH CLEAN SAND
1/8" PER FOOT \
BE LEVEL MIN. 2X MAX EL 99.0
GRADE MIN EL 97.0 2" LAYER OF
1/8"-112" DOUBLE
e WASHED STONE
tr
FLOW LINE 1 � � � ~
`- FL= 97.0 g 10" MlN. --- - nr NECK N
'^ o - EL = 96.0 t' POND f
£L- 95.5 - EL - 95.5 �',
o 0 0 0 0 0 0 0 0 LOCUS '
t it I' a o 0 0 0 0 0 0
4" CAST IRON OR � �" W
EQUAL ) PIPE - MIN. EL = 93.5 - EL 93.5 L. O6A TION MAY-)
---------------
PITCH 1/4" PER FT. 3/4" TO 1 1/2"
D fs'T DOUBLE WASHED
STONE 5 FT.
OUTLET TEE BOX _ _ _ 35 FT x 12 FT
LIQUID DEPTH TEE DEPTH >500 C IL
BELOW FLOW LINE
4 FT. 14 INCHES —
BOTTOM OF TEST HOLE OR OBSERVED WATER TABLE EL 88.5
5 FT. 19 INCHES TANff ADJUSTED GROUND WA TER TABLE ( / / ) EL =
6 FT. 24 INCHES
7 FT. 29 INCHES PROFILE' OF
8 FT. 34 INCHES
SZX,4CF DI,SIV,S7AL S'Y,S'TZAf
NOT TO S'CAL�'
DESIGN CALCULATIONS
NUMBER OF BEDROOMS .................................... 4
GARBAGE DISPOSAL UNIT .................. ............. NO
#1 DEEP OBSER VA RON HOLE LOG #Z DEEP OBSER VA TION HOLE LOG TOTAL ESTIMATED FLOW
DATE OF TEST SEPT 19 1995_ DATE OF TEST SEPT_19. 1995 ( 110 GAL/BR./DA Y x 4 BR. ) ...... 440 GAL./DA Y
W1TNEssEO eY ED eARRY WITNESSED Br BARRY __ REQUIRED SEPTIC TANK CAPACITY.................... 880 GAL.
ACTUAL SIZE OF SEPTIC TANK......................... 1500 GAL.
PERFORMED BY T. A. DUMAS PERFORMED BY T. A. DUMAS LEACHING AREA REQUIREMENTS ...................... 0. 74 GAL/SF
DEPTH FROM SaL SOIL SOIL SOIL DEPTH FROM SOIL SOIL sat SOIL LEACHING AREA PROVIDED
ELEV. SURFACE HORIZON TEXTURE COLOR MOTTUNG OTHER ELEV. SURFACE HORIZON TEXTURE COLOR MOTTLING OTHER SIDEWALL + BOTTOM
17 x 35.+..>;1 +3��.x.�.X.2..
608 S.F.
990 98,9 LEACHING CAPACITY (SIDEWALL + BOTTOM) .. 449.9 GAS
LOAMY SA 10YR5/6 I i 0 - 6" OAMY SAND10YR4/3 I i
RESERVE LEACHING CAPACITY...........................
16" - 36" B 'SANDY LOAM 10YR5/6
W 9 SANDY LOAM 10 YR6/8 95.9
36" - 120" C MED / FINE 10YR6/4 STONES O 72" NO TES'
96-1 STONES O 88.9 SAND CLASS I 1• ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TI7LE 5
'26" C MED FINE 10YR7/4 72" AND THE TOWN OF BARNSTABLE RULES AND RE-GULAT70NS FOR THE
88 5 SAND CLASS I SUBSURFACE DISPOSAL OF SEWAGE.
I , 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6 INCHES
I NO GWE ; NO GWE OF FINISH GRADE
3. EXIS711VG AND FINAL GRADES .SHALL REMAINE ESSEN77ALLY THE SAME, EXCEP
-� PERCOLATION TEST AS INDICATED
PERCOLATION TEST 4. NO DETERMINATION HAS BEEN MADE BY THIS OFFICE AS TO COMPLIANCE
DATE. 9 19 5 _ DEPTH OF PERC. 72" DATE: N/A DEPTH OF PERC. N/A WITH TOWN ZONING REGULATIONS. OWNER / APPLICANT SHALL OBTAIN SUCH
TIME: -_ 10:00 RA TE MIN. PER INCH _< 2 TIME: NIA RATE MIN. PER INCH NIA DETERMINATION FROM THE APPROPRIATE AUTHORITY.
5. THIS PLAN IS VALID /F IT IS STAMPED AND SIGNED IN RED. THIS OFFICE
ASSUMES NO RESPONSIBILITY FOR INFORMATION CONTAINED ON COPIES
#3 DEEP OBSERVA DON HOLE LOG #¢ DEEP OBSERVA TION HOLE LOG W41CH DO NOT HAVE ORIGINAL STAMPS AND SGNATURFS.
DATE OF TEST DATE OF TEST 6. ALL COMPONENTS OF 77-IE SANITARY SYSTEM SHALL BE CAPABLE OF
--- W1 THSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WI THIN 10
WITNESSED BY WITNESSED BY FEET OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR
PERFORMED BY -_ PERFORMED BY WITHIN 10 FEET OF DRIVES OR PARKING AREAS.
7 CONTRACTOR IS RESPONSIBLE FOR VERIFICAT70N OF ALL LOCATIONS AND
T ELEVATIONS, INCLUDING EXIS77NG UTILITIES, PRIOR TO CONSTRUCTION. IF
DEPTH FROM SOIL ; SOIL -SOIL SOIL DEPTH FROM SOIL ' SOIL SaL SaL ANY DISCREPANCIES ARE FOUND, THIS OFFICE SHALL BE NOTIFIED
ELEV. SURFACE HORIZON TEXTURE COLOR MOTTLING OTHER ELEV. SURFACE HORIZON TEXTURE COLOR MOTTLING DINER IMMEDIA TEL Y.
_- ----- - — 8. ALL UNSUITABLE MATERIAL SHALL BE REMOVED UNDER AND FOR 5 FT.
AROUND LEACHING FACILITY AND BE .REPLACED W1 TH CLEAN GRANULAR
SAND PER SECTION 15.255(3) OF THE STATE ENVIRONMENTAL CODE,
,7TLE 5.
9. EXIS71NG SANITARY FACILITY SHALL BE PUMPED AND ABANDONED TO
THE SA77SFACT70N OF THE LOCAL BOARD OF HEALTH.
i
i
I
REV
PERCOLATION TEST PERCOLATION TEST "D 95--565R-00 °oTF. SEPT 21, 199,5
DATE: DEPTH OF PERC. DATE: _ DEPTH OF PERC.
TIME -' RA IF MIN. PER /NCH TIME: RA TE MIN. PER INCH UiElv T. SCALE'_ ROCHE AS NOTED
DR. 9Y R. O'H. SHEET 2 OF 2
rr REGISTERED SANITARIAN APPROVED: BOARD Of X6.lLTX n LOCATION LOT 1 D , 55 XlANNO C 1AL CL,'
cJ. Hearn, PROFESSIONAL
LAND SURVEYOR LuT6 AGENT A)C4AR0 OSTI 'RIIILLL' BARNS'TA Rz ILIA
TAME$ q4`
35 RD U1I' s r' O. BOX 237
CO.Y.YBNTS o •i ASSESSORS MAP f¢0 PARCEL >OZ
SWAN RTVVh 'j[.AZA, UNIT 2 Surveyor
SOUTH TTH DFN%,i�, MA. 02660 '� ;~ y'
FLOOD ZONE. 0' ELEVATION._ N .Q MAP Dr; E.