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HomeMy WebLinkAbout0235 WIANNO CIRCLE - Health 235 WIANNO CIRCLE, OSTERVILLE A=-140 102 u a I e I (' r LLSEW ASSF.Sa01 $- APdoLOTS/`1� wo 3 I '" rWWO um At s a uadw T ble to the$ots6m df�each1 MR Fact Fn stS lat+u�uPPw'91 o andtaw �FAY whew=; ons�ta ar a�'it�n�E1Q,f�at bf.Tea�nl�gf ) �d�e o�wletid`andl cachia,��+ttY�fatEi'�rretlands exist : vrthlsi 3QU:fcet o€leaclu�ag�'ac : Feet l�urn�sbed byr'�• 4 C r � r Leetc(- gel 5 spa.. Li-I Commonwealth of Massachusetts Title 5 Official Inspection Form t, ! YII Subsurface Sewage Disposal System, Form.;Not for Voluntary Assessments - r 235 Wianno Cir Property Address r ,r: Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 . page. City/Town State Zip Code Date of Inspection + Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information , . .�1$F (413g0 Shawn Mcelroy Name of Inspector Upper Cape Septic Services a t r r Company Name P.O. Box 73 Company Address East Falmouth MA. 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in1he proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® -Passes a 2. ❑ Conditionally Passes. r 3. .❑ Needs Further Evaluation by the Local,Approving Authority 4. ❑ Fails 9-12-20 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth'of Massachusetts Title 5 Official Inspection Form C�,t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` V> 235 Wianno Cir r Property Address Janice Grady Owner Owner's Name information is required for every Osterville ` MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) Systems Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. System is using a precast leach pit as main tank and a leach pit for the leach field. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank'(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 ` Commonwealth of Massachusetts Title 5 Official Inspection Form i Y,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir ,. Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 F page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) , 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ' ❑ Observation of sewage backup or breakout 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 f= ❑ Y ❑N ❑" ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or,replaced' ❑Y ❑ N ❑ 'ND (Explain below): ❑ The system required pumping more than 4.times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: , ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety`or the environment: a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 . , Commonwealth of Massachusetts I�I Title 5 Official Inspection Form PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: ' Yes' No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f c Commonwealth of Massachusetts 1 Title 5 Official Inspection Fora hf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; 235 Wianno Cir t Property Address , Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) y 4) System Failure Criteria Applicable to.All Systems: (cont.) Yes No r: , ® 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 day flow " ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply z 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000'gpd to 15,000 gpd. w For large systems, you must indicate either"yes".or"no"to each of the following, in addition to the questions,in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official I nspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional.offrce of the Department. 6. You must indicate "yes" or"no"for each of the following for aH inspections: Yes No - ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? r - ❑ ® 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Fora. f� wa ,A i�l Subsurface Sewage Disposal System Form =Not for,Voluntary Assessments >' 235 Wianno Cir �T Property Address Janice Grady Owner Owner's Name _ information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). N/A Description: Number of current residents: 0 Does residence have a garbage grinder? , . .� ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) s Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: ;, . 2020 Date t5insp.doc•rev.7/2112118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Il ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Ostervillie MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: pate Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts fw Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments /ol _.J .> 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 4. Type of System: , ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy_ of latest inspection of the I/A system by system operator under contract ❑ -Tight tank.Attach a copy of•the DEP approval. ; ® Other(describe): System is made of 2-1000 gal precast leach pits. Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): , 18" Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ' ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ! , i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a r 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - 6. Septic Tank (locate on site plan): Depth below grade: 12"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: 1000 gal Leach pit Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 60" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 24" Distance from bottom of scum to bottom of outlet tee or baffle N/A Not at operating level How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There is a precast leach pit being used as main tank in good condition with baffles installed. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ^• Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ' N 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts (;p Title 5 Official Inspection Form I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 r Commonwealth of Massachusetts ,w Title 5 Official Inspection Form r'I Subsurface Sewage Disposal System Form Not for,Voluntary Assessments 235 Wianno Cir - Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , - r 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms'in working order: ❑ Yes ' ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: s leaching pits" � � � '-' =' - � `' number " � � " 1-1000 gal ❑ leaching,chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >` 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is Cisterville MA 02655 9-12-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 24" off bottom pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts IF- Title 5 Official Inspection Form a w: I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , ,>` 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is Osterville . MA 02655 9-12-20 required,for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): +" ' Materials of construction: Dimensions Depth of solids "' w Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form �Lr ,al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public_water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately L_-lam' 0', d t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 it Commonwealth of Massachusetts , fY Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments < 235 Wianno Cir Property Address , Janice Grady Owner Owner's Name information is required for every Osterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.), ; 15. Site Exam: < :. :_ • r _: . . i., ❑ Check Slope r ,- ❑ 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: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts + il Title 5 Official Inspection Form I� wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 235 Wianno Cir Property Address Janice Grady Owner Owner's Name information is required for every psterville MA 02655 9-12-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form lo Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay + U use the return Name of Inspector key. Shay Environmental Services, Inc. Company Name 185 Ashumet Road Company Address Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 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 spection.Tie ins�ction i was performed based on my training and experience in the proper function andm Intenance'of o"mite sewage disposal systems. I am a DEP approved system inspector pursuantuto Section;1-,A.34r!7 Title 5(310 CMR 15.000). The system: k , Z Passes ❑ Conditionally Passes ❑ Fai�s � ❑ Needs Further Evaluation by the Local Approving Authority Cy' r.., 4/12/13 _ 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. I I 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspec i n o m:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form MMI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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 A) System Passes: ❑x I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Overflow Leach Pit has No Liquid. 3.5' Stainline noted, primary leach pit(acting as tank) level is 3', with stain line to outlet tee. 2.5' effective depth available in overflow Leach Pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of r.mmnlinnra inrtirntinn that the tank is lase than 90 vaarc nlrl is availahlA ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment:. ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 I _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D System Failure Criteria Applicable to All Systems: Y pp Y You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ x❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ x❑ 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 ❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ x❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ x❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ x❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ x❑ 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.] ❑ x❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts M W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. CitylTown 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 x❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z Were any of the system components pumped out in the previous two weeks? ❑x ❑ Has the system received normal flows in the previous two week period? ❑x ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? n ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑x ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? x❑ ❑ Were all system components, excluding the SAS, located on site? ❑x ❑ 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? x❑ ❑ 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: x❑ ❑ 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)] 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 f Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection 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): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes x❑ No Laundry system inspected? ❑ Yes ❑x No Seasonaluse? rx1 Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ❑x No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): 'Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes x❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑x 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): Approximate age of all components, date installed (if known) and source of information: 1970-Precast pit acting as a tank with an overflow leach pit. Were sewage odors detected when arriving at the site? ❑ Yes 0 No 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Cisterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑cast iron Z40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑concrete El metal ❑fiberglass ❑polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 i Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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 El metal ❑fiberglass ❑polyethylene . El other(explain): 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No D-Box Present 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.): No D-Box Present Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑x leaching pits number: 2-6'diam x 6'D ❑ 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.): Overflow Leach Pit has No Liquid. 3.5' Stainline noted, primary leach pit(acting as tank) level is 3', with stain line to outlet tee. 2.5' effective depth available in overflow Leach Pit. 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 2.5' below outlet invert Depth of solids layer 5.5 Depth of scum layer 1/2 Dimensions of cesspool 6'x 6' Materials of construction Precast concrete Indication of groundwater inflow ❑ Yes x❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No evidence of hydraulic failure. Precaste Pit acting as a septic tank with an overflow leach pit. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,�. 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) J � p 02 3S \II n/Arvc t. ;tC/e-6WB8URFACB 8EWAOE DISPOSAL 8xarWA INSPECTION FORM PART C HY91'ElI=RMATION �. (e®Yvwd) P.wlay^dd...a =// .' 0"I D-!e-I le-p-.ti-os M IAKH 3 c ci(, 91I13CI'C8 OF 9139WAOE DXBPOSAIL 8Y89'®f: (bd.U-m-s)rR—p—.�+ns Lodm-r)v or barSm.rt� I—-U—n.wIOJ-700' t $ 4 5' asPrR'Io oRDVNaWwTss D.ptLmow-e-.etr-�s.c ���✓ S.q.S. � .ra —a.�amd(--:. cZT,T Q,�o�.sR./- y.S 6•S (r-.1-.a+)roaivs) o 235 Wianno Circle,Osterville,MA.doc'03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope 0 Surface water ❑x Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+feet feet Please indicate all methods used to determine the high ground water elevation: n Obtained from system design plans on record If checked, date of design plan reviewed: Date x❑ 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: Inspector has performed engineering design and perc test on this street. 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 i . r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is Osterville MA 02655 4/12/13 required.for every — page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay �� ,-I n v a use the return Name of Inspector " - Shay Environmental Services, Inc. Company Name 185 Ashumet Road Company Address r Mashpee MA 02649 Citylrown State Zip Code j 508-539-7966 3080 i� w 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ❑x Passes ❑ Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority 4112/13 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. j 5 235 Wianno Circle,Osterville,MA.doc-03108 Title 5 Official Insp ion Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 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 A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Overflow Leach Pit has No Liquid. 3.5' Stainline noted, primary leach pit(acting as tank) level is T, with stain line to outlet tee. 2.5' effective depth available in overflow Leach Pit. B) System Conditionally Passes: ❑ One-orsystem-components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of('mmnlinnrp indirntinn that the tank is IPCC than )n vpnrc nlri is nvnilahlp ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if - the system.is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines-in-accordance with-310 CMR 15.303(1)(b)that the system is-not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville _MA 02655 4/12/13 page. CitylTown State Zip Code IDate of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less-than 5 ppm, provided1hat-no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 0 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 9 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 235 Wianno Circle,Osterville,MAdoc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is Osterville MA 02655 4/12113 required for every _ page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑x Any.portion of a cesspool or.privy is within 50 feet of a private water supply well. ❑ rx-1- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the=well-water-analysis,-performed.at a-DEP certified- laboratory,for_fecal-_coliform.bacteria.indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ z The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Q The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System form Not for Voluntary Assessments �M 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityfrown 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 ❑x '❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑x ❑ 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? a ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑x ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑x ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? ❑x ❑ Were the-septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑x ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ 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)] 235 Wianno Circle,Osterville,MA.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville _MA 02655 4/12/13 page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Unk Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 9 No Laundry system inspected? ❑ Yes 0 No Seasonal use? 0 Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes Z No Last date of occupancy: Current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 235 Wianno Circle,Osterville,MA.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health 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: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑x 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): Approximate age of all components,.date installed (if known)and source of information: 1970-Precast pit acting as a tank with an overflow leach pit. Were sewage odors detected when arriving at the site? ❑ Yes x❑ No 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 235\/Vianno Circle Property Address William Sullivan Owner Owner's Name information is Osterville MA 02655 4/12/13 required for every — page. CityrFown State Zip Code 'Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5feet Material of construction: ❑cast iron Z40 PVC ❑other(explain): Distance from private water supply well or suction line: ' feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): 1.5 Depth below grade: feet p g feet Material of construction: h - ❑concrete ❑metal ❑fiberglass ❑polyethylene El other(explain) { If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy,of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 235 Wianno Circle,Osterville,MA.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is Osterville _MA 02655 4/12/13 required for every — page. CityrFown 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.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass El polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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 El polyethylene ❑other(explain): 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan _ Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No D-Box Present Comments(note if box is level and distribution.to outlets equal, any evidence of solids carryover, any evidence of leakage into orout of box, etc.): No D-Box Present Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is Osterville MA 02655 4/12/13 required forevery -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑x leaching pits number. 2-6'diam x 6'D ❑ 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, dampr soil, condition of vegetation, etc.): Overflow Leach Pit has No Liquid. 3.5' Stainline noted, primary leach pit(acting as tank) level is 3', with stain line to outlet tee. 2.5'effective depth available in overflow Leach Pit. 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is required for every Osterville MA 02655 4/12/13 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 2.5' below outlet invert Depth of solids layer 5.5' Depth of scum layer 1/2 Dimensions of cesspool 6' x 6' Materials of construction Precast concrete Indication of groundwater inflow ❑ Yes No Comments (note condition of soil, signs of hydraulic failure, level.of ponding, condition of vegetation, etc.): No evidence of hydraulic failure. Precaste Pit acting as a septic tank with an overflow leach pit. Privy (locate on site plan): ' Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 235 Wianno Circle,Osterville,MA.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15, ` Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 235 Wianno Circle Property Address William Sullivan Owner Owners Name information is required for every Osterville MA 02655 4/12/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 1,213-S 4.1:.Q/t.,t/C C..,/Ca�,e_9.188.]RFAQB S72WAOS DffiPOSA[.sxaxtale'INSPIDCr10Pl lro)aM HYBT®[INP'Oli11A110N Cooat9naed) „m,,,Q a3r woo CI�- Osr:// . D.te o!lary.alioar 1-7A c ci b - SHBlKM OY S7&'WA(18 DISIPOSAL S M M: faelm.dr fo al Ma.l c yezm.mvt.db•m./aodmsrk.� IsOta d)�aW elaLln lar ... .. 1 $ q _ CS � e� DBPi'8 TO OSOXOMWA.TBR m.tma-o[ee.emieasioa.�.yy .rinn:. CbT,T S • Crwlsed 17/C:3/95) 9 235 Wianno Circle,Osterville,MA.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Tine 5 -Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 235 Wianno Circle Property Address William Sullivan Owner Owner's Name information is Osterville MA 02655 4/12/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ❑x Surface water ❑x Check cellar ❑ Shallow wells 15+feet Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑x Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x 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: Inspector has performed engineering design and perc test on this street. 235 Wianno Circle,Osterville,MA.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of:Massachusetts Executive. Office of Environmental Affairs . • c `' �;. Department of Environmental Protection - qp Rcfi�� William F.Weld lT .. Xe s� GommdD Argeo Paul Cellucci W 0.Struhs, miado ," tL Governor 6orn / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..' ` PART A CERTIFICATION Property Address: Q35- w t AnnO C.re l G. — C�s j ear.lie Address of Owner. Date of Inspection: NA2•ttY3o�)►qQ6 y (If different) Name of Inspector. Ga 20 c•1.����v S Company Name,Address and Telephone Number. Gortoo� �Gv SOg-�i'd8- 5dyo CERTIFICATION STATEMENT QS 1cr.r.��t j,lA• Ua('sS­ I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: V Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails w r Inspector's Signat Date: ' The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. I INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: _ I have not found any information which indicates that the.system violates any of the failure criteria as defined in 310 Mt 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM COITIONALLY PASSES: One or,more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is ' imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-SSW Printed on Recycled Paper E � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(continued) Property Address: 3s�G✓i�nnc; C,zc/' - os�eru'l/c Owner. Date of Inspeotion:�"� arc H 3 O_)1 S Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). .The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER:SUPP.LIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform 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. 9) OTHER (revised 11/03/95) 2 a„ T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: �355/✓'/A"A/0 Cl"Jc Owner. I12 �TgMr� O'nt.i� Date of Inspection: 3 0/I Ci S b ' D) SYSTEM FAILS: t I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cloggei 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 H of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment.,program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prc')perty Address: a 3 s G✓i!!n,)o C,2 r lF D&W of Inspeotion: p,_,C H 3 0) kcL Check if the following have been done; _IZJPumping information was requested of the owner,occupant,and Board of Health. 44/'None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates / during that period. Large volumes of water have not been introduced into the system recently.or as part of this inspection. ,LAs built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. , The system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. system components,eaelnding the Soil Absorption System, have been located on the site. /'The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or / tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. /s T rs j �-Tc•n T j ,), -7-,/t size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. jL'The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION h Property Address Q 35'G✓I4nnv Owner. Date of Inspection: FLOW CONDITIONS,:: RESIDENTIAL] Design flow:_ 3Q Qallon8 Number of bedrooms: 3 + ," Number of current residents: Garbage grinder(yes w � =or no): } Laundry connected to system(yes or ao):�CJh { a" Seasonal use(yes or no):�f eJ Water meter readings, if available: I G5 7 y J ; Last date of occupancy:/(f—/C%� COMMERCIAL/INDUSTRIAL:- Type of establishment Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ i Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: •'~' __-� . . :-�-- _....� Last date of occupancy: OTHER:(Describe) Last date of occupancy: -. ,...� #.•, GENERAL INFORMATION PUMPING RECORDS and source of information: S�Sr<d�'l Y1� Crl f�Oc+-C C c.� �a (.-„'4 r `� yP,ti_1 11I� 1�C,,,,7 1�=��j�•,�vn!Q�.1 System pumped as part of inspection: (yes or no)i�i0 l 1 If yes,volume pumped: gallons , ..,.. Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(ea;,;ain) C� APPROXIMATE AGE of all components,date installed(if known)and source of information: 2 rA& -j3,•,Zr 9> Sewage odors detected when arriving at the site: (yes or no)�O - s a., .:. (revised 11/03/95) 6 " " '•^ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s f PART C SYSTEM INFORMATION.`(oontinued) " Property Address. 1�12= �amNs O`k��,�� Owner. /l Date of Inspection: P)�fvcr� 3a� k J (locate on site Depth below grade6.'�4 " Material of construction::_Zwncrete metal:_FRP—other(explain) Dimensions: ., Sludge depth: Distance from top of.sludge to bottom of,outlet tee or baffle:_ Scum thickness: k; Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to.bottom of,outlet tee or baffler Comments: (recommendation for-pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) 'n r� , .-SAIiQr !�c dv I e 7" /ce i/JJ/!t/C• GREASE TRAP: (locate on site plan) n Depth below grade: Material of construction:_concrete_metal FRP other(explain) 10 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet-tee or baffle: Comments: (recommendation for pumping,condition of.inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) i (revised 11/03/95) 6 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a3S (,—%(Aa na C,r A c Owner. Date of Inspection MArcn 3c��► b TIGHT OR HOLDING TANK:_ (locate on site plan) a Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity:_ gallons Design flow: gallons/day s, Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX:_(/ (locate on site plan) Depth of liquid level above outlet invert: , Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of bog,etc.) PUMP.CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) , Comments: (note condition of:amp chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 °'`4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address a3'� L✓lHnna C;,er% - Gs✓"V Owner: 192.5AnjCJ C)"n C i Date of Inspection: PI'vc.1-i 30)(5 S 6 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits, number: d X 6 leaching chambers,number: — leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of ydraulic failure, level of ponding, condition of vegetation,etc.) li V/1 CESSPOOLS:_ (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: Mow(cesspool must be pumped as part of inspection) 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,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) y Property a3 Address: Owner. �WA,-j O,,)C't ll Date of Inspection: 6 I'7q,CH 3Oj I Ci Cj SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' T l DEPTH TO GROUNDWATER Depth to groundwater: 3�,_feet method of determination or approximation: . OJT,7 Qv, 02.E (revised 11/03/95) 9 TOWN OF B STABLE LOCATION A// SEWAGE # i� �fie� VILLAGE 111L ASSESSOR'S MAP &LOT V-0- tb1 0" INSTALLER'S NAME&PHONE NO. G O rzn�nvrv3— SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 6 x 6 P' r (size) NO.OF BEDROOMS-3 BUILDER OR OWNER 6Mr� Ors CJ, , f PERMITDATE: K COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 6 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A1%A) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feettoof leaf hin facility) %IA Feet Furnished by lr — � 313,pl%b �- �4 �� ,- 31 ` ` P�—� a� ' a��T � ._ � i