HomeMy WebLinkAbout0021 WINDRUSH LANE - Health A Windrush Lane
Osterville
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UPC 10247
NO. H163GN
HASTINGS. MN
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Terrie Reilly
508.776.6182 mobile
508.362.1414 office
treilly@robertpaul.com
ROBERT PAUL n
PROPERTIES
CAPE COD I BOSTON
3256 Main Street, Barnstable
www.RobertPaul.com
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Terrie Reilly
508-776.6182 mobile
508.362.1414 office
treilly@robertpaul.com
ROBERT PAUL
f �@ PROPERTIES
! CAPE COD I BOSTON
3256 Main Street, Barnstable
j WWW.RobertPaul.com
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LEADING ESTATE
REAL ESTATE
PORT LIO COMPANIES'
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L0,CAT10N� SEWAGE PERMIT NO..
- 4,
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J YILLAGE 211.
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INSTA LLE 'S ME & ADDRESS
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BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED , � �+
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TOWN OF BARNSTABLE
LOCATION 1 L4,11 SEWAGE# «
VILLAGE C)C Y,y j j)f ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. Q �& ,jj:
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) t 9L1 � L��1;� �Aid (size) 83,< J3
NO.OF BEDROOMS
OOMS
OWNER A ht c,4 c�►�t
PERMIT DATE: / 2 6 COMPLIANCE DATE: 1116 AV 4V
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY i
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No. v v 2Q ' Fee / 5V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
01pplitation for Misposal 6pstem construttion vermit
Application for a Permit to Construct( ) Repair(el-11upgrade I; ) Abandon( ) ❑Complete System ndividual Components
Location Add ess or Lot No. Owner's Name,Address,and Tel.No.
0si-ef.r,1)
Assessor's Map/Parcel 0U 06
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: 00t
Dwelling No.of Bedrooms �113 l Size A 0 3 arr!) sq.ft. Garbage Grinder
Other Type of Building resl('PN}-iCt No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) l J gpd Design flow provided ys S gpd
Plan Date n)`Z� 7)2na-C Number of sheets Revision Date
Title c7
Size of Septic Tank 06Lty iNS Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) '� // 4 n/ i-J rv✓
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe �--��— Date foVc)
Application Approved by 4 Date�-91 14W-, 14 0
v e:
Application Disapproved by Date
for the following reasons
Permit No. �0�� 3 s Date Issued t 0 ��
ittEK.... »:a r Eck ..'"� •. #. }
No. Fee;
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: _ >„
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS s
2pplicatio.n for MiBpoSal 6ps,tettt.Co
erlttlt
Application for a Permit to Construct( )' Repair(alf Upgrade( ) Abandon(.) E Complete System [jddiidual Components
Location Address or Lot No. -Owner's Name,,Address,and Tel.No. s
Assessors Map/Parcel
Installer's Name,Address,and Tel.No. Designers Name;;Address,and Tel.No.
Type of Building: dt
Dwelling No.of Bedrooms pIt)s I $.LJ � Size F ' sq.ft. Garbage Grinder( )
Other Type of Building /PS1f)Pn14 n No.of Persons .. Showers( ) Cafeteria( )
:'—- �• Other Fixtures
TDesign Flow(min.required_) Li.Il god Design flow provided l�s " ti tit eee... gpd p
Plan Date CA��..>-n�n Number of sheets' Revision Date°gip„k A a (V
- Title x 4
Size of Septic Tank 62" ", k Type of S.A.S.'Y V.
,Description of Soil _ T v
4 Nature of Repairs or Alterations(Answer when applicable)
, a
<-00 CA tAoro A -Il) flnf Vu P(c fit hOrIV> r 40rJe Cis pet 91Ga)
v
Date last inspected: i
Agreement:
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The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal+system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed V '.Date
Application Approved by Date
Application Disapproved by U Date
;
for the following reasons
Permit No. 0 - `S , .,. 'its, Date Issued I U
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABL•E,MASSACHUSETTS
Certifirate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�/}� Upgraded( )
Abandoned( )by ! `�� ,I jr',.t n1 1 Aic
at ) 1A)1 � t e� L f��4r/tI �1 1P has been constructed in accordance
-►r i_ :� _ , t
with the provisions of Title 5 and the for Disposal System Construction Permit No. Q�v"3/3dated i A/�, A
-q- _1
Installer 1�A .�UCLA ��\ 1-,n1( Designer
..r - — _. p. ,� yr•v v v r ...
#-bedrooms. . gPa
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The issuance of this permit shall not be construed as a guarantee that the system willful et on as designed.
Date Inspector -
. _ s
No. Fee
THE COMMONWEALTHiOF MASSACHUSETTS =
PUBLIC HEALTH DIVISION,=BARNSTABLE,MASSACHUSETTS
loisposal *pstem,Cone.t union permit
Permission is hereby granted to Construct( ) Repair(' Upgrgd/e( ) Abandon( )
System located at ') / L1.'';iv dy o C.)4 4/w V S�t f t//l/ e C
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
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Date b ! `j. .. Approved by
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THE COMMONWEALTH OF MASSACHUSETTS
BOARDr E L ' .
.......OF...........
............
Apphration -for 4iupoiial Workii Tomitrurtiou Vrrmft
Application is hereby'made for a Permit to Construct (k-f'or Repair an Individual Sewage Disposal
System at fi
1...W14 d.......!��// ................ ....................................
........................... ow,4 r �............................... ---------------------
..-.-.-.-..--.-.-.-.-.-.
-.-..--..--..--.-..-.-.-.--..-.--..-.-.
AL3 0t' Add or lh N
.k- fta 6 J--_-------------------------- ----77g 5 oil -.-.-..-.-.-.-.-.-..............
�1.. . n. -----------------------Address .........
...
-----
Installer Address
Type of Building Size Lot.... S`q, feet
U
4-- Dwelling—No. of Bedrooms.---_-- ....2—
...............................Expansion Attic Garbage Grinder ( --I
-1
PL, Other—Type of Building ---------------------------- No. of persons.-._____----______---____.-_ Showers Cafeteria
Otherfixtures ------------------------------------------------------------------------------ ----------------------------------------------------------------------
Design Flow.......57D............................gallons per person per day. Total daily flow.....AQ0----------------------------gallons.
P4 Septic Tank Liquid capacity-L500-gallons Length---------------- Width---.-..----_-.- Diameter.-.-_--.-_--_- Depth----------------
Disposal Trench-A—No_____________________ Width....Ir-------------- Total Length_.....__....._....-_ Total leaching area----- --------------sq. f t.
Seepage Pit No...../.............. Diameter..../.!?.......... Depth below, inlet.....j6........... T I l*nhing area -----------sq. it.
Other Distribution box Dosing tank ( - 434M
d- Q;La
Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------------- ------------------
Test Pit No. I----------------minutes per inch Depth of Test Pit-.---_.-__________-. Depth to ground water-------------2----------
Test Pit No. 2................minutes per inch Depth of Test Pit._..._............_. Depth to ground water--.--..--__----._-__-.
�' ---------------------------------- ------r--------
0 Des Desc iption of Soil---------
4 or. , .......
le,40 rn-ot.,V
U ................
0— -----------------------------------
-------------
. . . .....0
------------------------------ -------------------------------- .. . .. .....//^----------------------------------------- --------------------
--------------------------
U Nature of Repairs or Alterations nswer when applicable.______________------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------------ .........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has . ued by thlboard of health.
I I ed.. .. . ......
e ... . .................................. ................ --------------------------------
Date
. . . .. ......
Application Approved By------------ -- ------ . .... ........ ... ......
Date
Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------
............................... .........................................................................................................................................................................
Date
PermitNo......................................................... Issued-------- .............
Date
---------------------------------------------------------------
No....... Fas...............................
'THEBOARD COMMONWEALTH
OF MASSACHUSETTS
-r SACHUSETTS
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„:eAppliration 40r Dhivolltti 3 >arkii C onlitrurtilan Vrrutit
Application is hereby made fora"Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:,p ,.
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Addr s r L No
�a ' _A g ' afar ►_ _C[?t!1 ............................. .. l .........
Owner r,_. Address
W .. ..
Installer c Address
d Type of Building Size Lot.... feet
..._...____..--____:._.Ex Expansion Attic Garba e Grinder
U Dwelling—No: of Bedrooms.___ p ( ) g
Other—Type of Building _ ____._..___s-.-_.____-__ No. of persons...------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------
W Design Flow........r8-------------------------------------------gallons per person per day. Total daily flow...-.:! qO-_..._-...__-_____._..__._-_gallons.
1:4 Septic Tank L Liquid cau�ity i5 gallons Length _______________ Width___-------------- Diameter---------------- Depth_. ..._____._ .
x No.
___________________ �l/Ali_ -Total Length-------------------. Total leaching area-------------- -----sq. ft.
Disposal Trench
3 Seepage Pit No.... .............. Diameter _ _ Depth beloN inlet-----6- ____-_ T 11 a hiug area.-
Z Other Distribution box ( ) Dosing, tank ( ) y,.•�r ' ': '
Percolation Test Results Performed by ____ _________ ______________________________ Date__----.--__._ -.______..______-__ .
Test Pit No. 1----------------minutes per inch Depth of Test Pit_.................... Depth to ground water.- . -- . _.__.__._....
1:14 Test Pit No. 2................minutes per, inch,.':.Depth of Test Pit.------------------- Depth to ground water__.__..._- ______._.
oDesc iption of Soil.------ 49""-- --------.
' = ------
�A------------------------------------- --- ---------------------- -
V Nature of Repairs or Alterations— nswer when applicable..______--------------------------------_--------------------------------_-----------_----------
----------------------------- --•-•- . ----- - -- -------
Agreement
Tl e undersigned agrees.-.to install the,`aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanit iry.Eode :-The undersigned further agrees not to place the system in
operation until a Certificate of Compliance,has ued by th . board of health.
Sied ---------------- . -
Date
Application Approved By..... --•- - - ------ --- -- -- "
�.
Date
Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------.•-•-----••--•-
•---•---•--•--•-•---•--------------------------•---............................................-----------------------------------------------------------------------------------------------
Date
Permit No........................----•• ------ Issued.------...---- --L-Y--- --- --.•---•--•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OX, HEALTH L t'
........OF........ A��"P ^'" "..............................
,T3
Trrtif irate of 0,11mV1iaurr 4,
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired.. ( )
by ------------------------------------ -
' nst111er
at ..... ...................................... -•..---
has been installed in accordance N the provisions of :. �1 XI of The State Sanitary Code as described in the
application for Disposal Works'Construction Permit No: 12__ .............. dated ..__.__
2 3
THt ISSUANCE OF THIS ICERTIFlCATE SHALL. NOT RE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY..
.. a, 7 7 Inspector _--IrDATE. - -- -- ----•------------------------- Ct
THE.,COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
No.. -- ....... FEE----r ...............
YN4
ermission is hereby granted ,;----------------- ---------------------- ... �C- ?,o.. ------- :_. _._....
4 to Corist ct (A or Rep r i !du,, Se ge Dis oral stem
` at Noy t/ � � s
+R.+�`t ------.
ta' - Street
as shown on the application for Disposal W.-ks Construction P t No. __ bated.. "' _ "'
----------------••-
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DATE-- <.._ a77� --- t
Board ofilIeal h
FORM 1255 HOBBS & WARREN. INC.: P.UBLISHVERS,
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Commonwealth of Massachusetts � �
Title 5 Official In Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is required for OSTERVILLE MA 02655 8/20/07
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: A. General Information
When filling out
forms on the
computer,use 1. Inspector: ' pT
only the tab key �S Uv
to move your MICHAEL DEDECKO
cursor-do not Name of Inspector
use the return
key. COMPASS REALTY DEV CORP
Company Name
rsb P.O. BOX 2384
Company Address .
MASHPEE MA 02649
n City/Town State a Zip Code
508-221-5003
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 insection. T:he inspection
was performed based on my training and experience in the proper function and m` intenance of on'site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section,.'15.340;of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluatio y the Local Approving Authority
.
8120/07
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to.the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
21 windrush•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
01 21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OS TERVILLE MA 02655 8/20/07
required for Inspection
State Zip Code Date of p
every page. Cityrrown
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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 Compliance indicating that the tank is less than 20 years old is available.
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 15
21 windrush•08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for every 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
x f 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. 1 of public water
❑ The system has a septic tank
and SAS and the SAS is within a Zone a p
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
21 windrush•08106
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE % MA 02655 8/20/07 _
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
C)" Further Evaluation is Required by the Board of Health (cont.):
Q The system fias 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:
I - o r coliform
} a DEP certified laboratory, fo
** stem asses if the well water analysis,;performed at ry
This system p
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be+.
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"-to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system acomponent due to overloaded;or
clogged'SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
® due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
r , P
® or 'clogged SAS or cesspool
® Liquid depth in.cesspool.is less than 6" below invert or available volume is less
El 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
E ® tributary to a surface water supply.
Form:Subsurface Sewage Disposal System Page 4 of 15
Title 5 Official Inspection
21 windrush•08106
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form : a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
E] �® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd. 5
® The system fails. I have determined that one or more of the above failure
El 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
❑ 0
Area IWPA)or a mapped Zone Il of a public supply well
f t
If your# ave answered "yes" to anyquestion 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.
e
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
21 windrush•08106 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System.Form -Not for Voluntary Assessments
wM 21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. City/Town
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ®• Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
❑ ® this inspection?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected fo'r 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?
O ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a'plan at the Board of Health.
® ❑ Determined in the field (if any of the'failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
21 windrush•08106
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 WINDRUSH LN `
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655' 8/20/07
required for State Zip Code Date of Inspection
every page. City/Town
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: 11.0 gpd x#of bedrooms):
330
0
Number of current residents:
Does residence'have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? 4 El Yes ® No
Seaso nal use? ❑ Yes ® No
n/a-
Water meter readings, if available (last 2 years usage (gpd)):
_ ❑ ®
Sump pump? Yes No•
` N/A
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:`
Design flow(based on 310 CMR 15.203): Gallons Per day(gpd)
r-
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present?. El 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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
21 windrush.OE106
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w„ 01 21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
General Information
Pumping Records:
n/a
Source of information:
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
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
El maintenance
technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1977
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
21 windrush•08106
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
21 WINDRUSH LN
Property Address `
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 --
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cost.)
Building Sewer(locate on site plan):
Depth below grade: feet '
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints tight, yes vented, no sign of leakage. .
Septic Tank(locate on site plan):
a 6"'
Depth below grade: feet
" f n
.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
----- - ------------ -----
1000 gallons
Dimensions:
3"
Sludge depth:
3111
Distance from top of Sludge to bottom of outlet tee or baffle
Scum thickness
lit,Distance from top of scum to top of outlet tee or baffle
14„
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of'15
21 windrush•06106
I
Commonwealth of Massachusetts
• n Form
Title 5 official Inspe
ction
Assessments
Subsurface Sewage Disposal System Form -Not for Voluntary
a
wM 21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. City/Town
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.):
no need to pump tee's intact, structurally sound, liquid level equal with outlet invert no leakage. _
Grease Trap (locate on site plan):
Depth below grader feet
Material of construction:
❑ concrete' ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): .
Dimensions:
t
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 ❑ polyethylene ❑ other(explain):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
21 windrush-08106
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 21 WINDRUSH LN
Property Address {
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE °: MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. City/Town - 'w
D. System Information (cony.) ,
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: 2 Alarm'in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
e,
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
equal with outlet inverts
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.):
D box is level and distribution is equal, yes solid carryover, no signs of leakage. -
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
21 windrush•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
i ,
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOU I H RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cone.)
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: • ,
® leaching pits number: 2/6x4.
❑ 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.):
soil sand,.no sign of hydraulic failure, ponding dry, no damp soil,.vegetation normal. +
21 windrush•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts ,
r Title 5 Official Inspection Form
} a Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments
21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE-MA 02632 _ A.
Owner Owner's Name
information is OSTERVILLE -MA 02655 8/20/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
f
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 w ❑ Yes ❑ No
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.):
21 windrush•08106 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
w„ 21 WINDRUSH LN .
Property Address
C/O DAVID HOLT 1533 FALMOUTH RID CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 8/20/07
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information(cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent referen
ce landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
3
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
21 windrush•06106
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 WINDRUSH LN
Property Address
C/O DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632
Owner Owner's Name
information is OSTERVILLE MA 02655 -8/20107
required for
State Zip Code Date of Inspection
every page. Citylrown
D. System Information .(coat.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
14.91'
Estimated depth to 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: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑, Checked with local excavators, installers-(attach documentation)
• :k
® Accessed USGS database-explain:
town of barnstable gis
You must describe how you established the high ground water elevation.:.
town of barnstable gis
21 windrush-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Town. of Barnstable
op 1He rp�
Regulatory Services
BAMSrnB Thomas F. Geiler, Director
9$A 6 9 ••� Public Health Division
TFn u�ar"
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface-Sewage Disposal System Form - Not for Voluntary Assessments µ
°M -Windrush Lane —-
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
'.
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. 093_'ej70
Important:When filling out A. General Information
forms on the w
computer,use 1. inspector: %
only the tab key
to move your Robert Paolini .
cursor-do not Name of Inspector N 1
use the return A
ke . CaP p ewide Enter rises LLC -.
y
_ e '
Company Name
C16 P.O.Box 763 e :
Company Address
CD
Centerville Ma. 02 32 P-
' City/Town State Zip ode
(508)428-4028
Telephone Number License Number _ --
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and;maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant'to'Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Poluation by the Local Approving Authority
5/11/2007
Ins ector's Eribnature 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. n
****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.
21 windrush lane•08/06 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
143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is Osterville Ma. 026455 5/11/2007
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection.Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are �.._
indicated below.
Comments:
The septic system is in proper working order at the present time.
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. a,
System will pass inspection if the existing tank is replaced with a complying septic tank as T,
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.
ND Explain:
r
❑ 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
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
ID Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 143 Windrush Lane
M
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Cisterville Ma. 026455 5/11/2007 "
every page. City/Town State Zip Code Date of Inspections
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
L supply well.
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
1
Commonwealth of Massachusetts �y
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every page. 'City/Town 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 M
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No � -
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert d,ue 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
El ® 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.
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
r
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification cont.
D) System Failure Criteria Applicable to All Systems (cont.): M<x
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable,water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cess ool servin a facility with a design flow of 2000 d-
❑ ® Y P 9 Y 9 9P
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the.system fails. The
system owner should contact the Board of Health to determine what will be - -
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ 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.
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
143 Windrush Lane _
Property Address '
Jerry Murphy
Owner Owner's Name
information is Osterville Ma. 026455 5/11/2007
required for
every page. City/Town State Zip Code Date of Inspection
C. Checklist N
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® 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) _
Z ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out? -
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
El ® 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)] __.. .
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
^M 143 Windrush Lane
Property Address
Jerry Murphy
Owner. Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 - Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 . . .
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ®'. No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
2005:387,000
Water meter readings, if available (last 2 years usage (gpd)): 2006:313,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/11/2007
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):
L21rush lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name ......
information is required for Osterville Ma. 026455 5/11/2007
'- °
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records: _
Source of information: J.P.Macomber
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
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any).
El maintenance
technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval..
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
21 windrush lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
2'
Depth below grade: feet.
Material of construction: -T
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: e°t+
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System is vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
-------------------- ----------------------------------------------------------------------------------------------------..n..,. ,
Dimensions: 1 0'6"x5'1 0"x57'
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
22"
Scum thickness 3„
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
/
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M s 143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
q
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, x
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No
evidence of leakage.
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other (explain):--"
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 ,
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form J
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 143 Windrush Lane -
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
i
Design Flow:
gallons per day
t
Alarm present: ❑ Yes ❑ No K,..�.
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date •-..4tA.
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
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.):
Box is Ievel.No evidence of solids carryover.No evidence of leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
21 windrush lane•08106 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
M 143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every 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:
® leaching pits number:
2 .
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
µme.
❑ 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.):
Sandy soil.No signs of hydraulic failure.Pit#1 water to invert was 13".Pit#2 was 38"to invert at time
of inspection.
21 windrush lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
----....;,ter.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
143 Windrush Lane „�.
Property Address
Jerry Murphy ---
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007 -"
every page. City/Town State Zip Code Date of Inspection
1
D. System Information (cont.)
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, A w
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.):
21 windrush lane•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
v
Commonwealth of Massachusetts .
W Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 143 Windrush Lane
Property Address
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
396
d
21 windrush lane-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
LLe, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 143 Windrush Lane
Property Address
i
Jerry Murphy
Owner Owner's Name
information is required for Osterville Ma. 026455 5/11/2007
�..,..
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) 2yx;
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 15'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date . .�
® Observed site (abutting property/observation hole within 150 feet of SAS) m...
❑ 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.-
Used:Gaherty& Miller model 12/16/94 ground water elevations.Used:USGS observation well data
June 1992.Used:Technical bulletin 92-000-01 Plate#2 annual ranges of ground water elevations.
21 windrush lane•08.+06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
,per
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR:
DEPARTMENT OF ENVIRONMENTAL PROTECTP
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEN).S
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: Z ^'�AIDR�Lf L.,gi✓E (Z' Lac 7
Owner's Name: 02 S o! v RR , v�A-s &Rleq
'Owner's Address: !GC uc,J lrt9,� /
/to Ocj/o
Date of Inspection: / - /y-O 2
Name of Inspector:(please ��wAR� �• CJ Tom=
Company Name: 91riot) 7-4/r-
Mailing Address: /¢/ r /} 7`4 ;6 l /729
Telephone Number: ®B 8— 3G/ ,9
CERTIFICATION STATEMENT
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 functiow d maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
►-Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai
Inspector's Signatu Date: °"/r 02-
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'pf 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.
Notes and Comments $? /�✓ �!�'U ` ' /C P,&-cr7-1n4e-
L� �Q lv-&1� e—�77� 02e44,t J< �
/f `—� 7a �R i v�/�✓� T/f�0 c E�-Trr- �-C �.J `
**T '¢ ./1 /,; '�'�h/Lt�✓If �l'��Z E- VI"dJIrMol W4177 �/ CU�2�Z/E/E��r�f�i v�/0-AX
This report only describes conditions at the time of inspection and under the co ditions 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
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
ccc-
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
�A System P es:
found any informationfailure criteria 15.303 or in 310 CMR 15.04 exist.Any fail a criteria note evaluated are indicated below.described in 310 CMR
Comments:
s-12X�? /-I/ � �2fcr-r/y Dao
System Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not termined(Y,N,ND)in the for the following statement
explain. please
If"not determined"ple
The septic tank is metal an ver 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltrat or exfiltration or tank failure is imminent.System will pass inspection if the ~
existing tank is replaced with a comp) ' eptic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if i ' structurally sound,not leaking and if a Certificate of Compliance' `
indicating that the tank is less than 20 years old vailable.
ND explain:
Observation of sewage backup or break out or high sta water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distributio ox.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND, :plain:
_ The system required pumping more than 4 times a year due to broken or obstructed pipe The system will
pas ispection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND IkAin,
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �/���tdl�ds/� ��✓
Owner: tifI°�d
Date of Inspection: /S'— z
C. urther Evaluation is Required by the Board of Health;
C ditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to tect public health,safety or the environment. ,
I. System wi ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not nctioning in a manner which will protect public health,safety and the environment:
_ Cesspool or pri is within 50 feet of a surface water
Cesspool or privy i within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of He h(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protec he public health,safety and environment:
_ The system has a septic tank and soil absorpti system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water su ly.
_ The system has a septic tank and SAS and the SAS is ' in a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 0 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 10 eet 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 la ratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollute from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, ovided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other.
3
Page 4 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2
Owner: dR�ffY
DateofInspection:
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
L' 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
/
_ 4 Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pum
ped
ped
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.
AA 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.[This systems passes if the well water analysis,:
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
••// are triggered.A copy of the analysis must be attached to this form.]
Na (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
Large Systems:
To be idered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You ni gust indicate et "yes"or"no"to each of the following:
(The f)flowing criteria app large systems in addition to the criteria above)
yes ro
the system is within 400 feet of a sur drinking water supply
the system is within 200 feet of a tributary to a s drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhe otection Area—IWPA)or a mapped
Zone II of a public water supply well
If yoe /e answered"yes"to any question in Section E the system is considered a significant t,or answered
"yes" ection D above the large system has failed.The owner or operator of any large system cons ed a
sip; threat.under Section E or failed under Section Dshall upgrade the system in accordance with 31
15.31 ie system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I '
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES1 ITS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FG
PART B
/ CHECKLIST
Property Address: '''/o'QvS` ZAI
Owner:
Date of Inspection: /v - /.f- o-z-
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
7 CO _ Pumping information was provided by the owner,occupant,or Board of Health
AWere any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
fvccun�
_ Were all system components, the SAS,located on site? M
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of 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:
Yes no 1 �-
1r _ �dic f- va rc •�C ate/S� ��1/Si�
r` Existing information.For example,a plan at the Board of Health. �S c
Z¢� G-/9-7 /a-9.qT
/i✓ z&ews 614r, *41tr ivs � se1
Ts-unacceptable)
� _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation o distance
is unacceptable)[310 CMR 15.302(3)(b))
Dot/ a'
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: //4/0 "y���✓
Siva✓/<<C
Owner:
Date of Inspection: /o—�
FLOW CONDITIONS �� B ✓( t s Esc r�
RESIDENTIAL =,8•rh4 a o.aw�2 b rzs)
Number of bedrooms(design): Z Number of bedrooms(actual): ra esrr> y I'llPxrrv2.sr
C �
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): D d`
Number of current residents: 2— """f_
Does residence have a garbage grinder(yes or no): 410
Is laundry on a separate sewage system(yes or no):-j[if yes separate inspection required)
Laundry system inspected s or no):_
Seasonal use:(yes or no):JW
Water meter readings,if available(last 2 years usage(gpd)): ;4"d 133704)y•� Zod / 13Z�1eo 49onv
Sump pump(yes or no): OVO
Last date of occupancy:
CQM_M ERCIA VINDUSTRIA L
Type o lishment:
Design flow(batdAQ10 CMR 1 S.203): gpd
Basis of design flow(sea ons/sgft,etc.):
Grease trap present(yes or no):_ —
Industrial waste holding tank present(yes o
Non-sanitary waste discharged to the Title S system or no):i
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): }
GENERAL INFORMATION
Pumping Records
Source of informatiom, p v'y Zoa�
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: �✓X- eallons--How was quantity pumped determined?
Reason for pumping:
PE OF SYSTEM
Septic r.
p 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
obta fined from system owner)
'fight tank =Attach a copy of the DEP approval
Other(describe):
Af oximate age of-all components,date installed(if known)and source of information:
WP ;;wage odors detected when arriving at the site(yes or no): /✓v
Page 7 of 11.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ;r`L(A&11•v0/1vs# ZJ/
s7/TA /27 77
Owner: MVQ psi 7
Date of Inspection: /o-t r_a z
BUILDING SEWER(locate on site plan)
Depth below grade: 2 r� Alb c. /*v
Materials of construction:_cast iron ,�40 PVC_other(explain): ��'p ••�r«ter,vim 'Fs�<<Ettl/
Distance from private water supply weft or suction line:�,}-
m '`""'ram
Comments(on ond'tion of'oints,venting,a idence of leakage,etc.):
4//C7y C 4 it*L-1/ a V S 4•�O/ Wye-xmr4et)
SEPTIC TANK:_(locate on site plan)
Depth below grade: p
Material of construction: concrete metal fiberglasst_polyethylene
_other(explain)-- f�d S r' G✓eQe-� i.Sb06 4e. �g,�
If tank is metal list age:_ Is age confirmed by a C;ztificate of Compliance
p (yes or no):—(attach a
' certificate) w�0•� �C �varlt X fsricgr copy of
Dimensions: 5 -!4•�x /D '= G n X S t G > wlf'ex. Z'��rvr,.vr-ro,Q•rmr'vw)
Sludge depth: /
Distance from top of sl dge to bottom of outlet tee or baffle: 29 "
Scum thickness: 9, wo Scr//y
Distance from top o scum to top of outlet tee or baffle: ryo S wn-i 17V d41"
Distance from bottom of scum to bottom of outlet tee or baffle:_ a scams G e'Q M 9a r-rTV'/7
How were dimensions determined: yl41*5b24�7 4,yq 7-#oXj AW SeGLr'
Comments(on pumping recommendations,inlet andjut �tllet tee or bales condition,structural integrity,liquid evels
as related t o tlei'invert,evide ce oj.leakage,etc.):
S4*40 /P t sc
/'✓�7'- 3 lZ"rwlsvelve- "'''�/O"•`i�v.•.u•.t ._ Go�q ,e'ca.t)� 6000 SO�Zrt�L�i�4g�
Ld-1/bZ , G,tt� x' u�/lE/L. ?�Nr� s!`g'J Z `'r0/F�ata.�tYl� �rtur��,✓T�r�+-PrL�re¢tT
x/2yy�ec�r, e4�,•v*e-�iewafgc�i2� �rce-T-
GREASE TRAP:_(locate on site plan)
Depth below grade:_
'2'ria
construction:_concrete metal fiberglass__ _polyethylene other
plain): _"
I:)imensions:
Scrim thickness:
I Distance from top of scum to top of outlet tee o
I,istance from bottom of scum to bottom of outlet tee or ba
I'ate of last pumping:
,)mments(on pumping recommendations,inlet and outlet tee or baffle conditto , ctural integrity,liquid levels
..,related to outlet invert,evidence of leakage,etc.):
7.
Page 8 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES;, ANTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FC
PART C
SYSTEM INFORMATION(continued).
Property Address: 0'2/141/40,¢e
Owner: vgisrr
Date of Inspection: /0— /1--aZ
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: to metal fiberglass -----Polyethylene
other(explann):
Dimensions:
Capacity:_ allons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):_
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
fi r?.
DISTRIBUTION BOX: _(V if present must be o ened locate on �6 'Y
P )( site plan) X
Depth of liquid level above
9 bo a outlet Invert:,��Z�Gv��� �✓�2
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.): ��f,�Q ,
/.���''� d
!,'� ��L����L Ot.�. �Yo f�" TJfb�LB'T-'� � j u�S mR ,��� � �-•�Ar
P MP BER: (locate on site plan) SyS� �y� �
Pumps in working ord�or
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps a nances,etc.):
Page 9 of 11 }
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:4 21,444tulsht �N
�Y
Owner: y y
Date of Inspection: /a -- %S'-02
SOIL ABSORPTION SYSTEM(SAS): V{locate on site plan,excavation not required)
If QAS A located ex lain
o.&-2&,t4Lec E-�s
_ _ _ �.
T-.�. 2
I - E�FK�7 � /�lGffT�rZ �?ZGdc�7 6✓�- S/�®r .�-G7
Tpp'Z9"eaching pits,number:_ C/3orTzM) /d i9/#,
leaching chambers,number: 'Fr-1-live .
leaching galleries,number: r�
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 priding,damp soil,condition of vegetation,
ti etc.): )
2 'z '' lRtl p ��hrij-�i/i vyl /' "Fir. l� � ���z�•�,c
.v/Jrrrwv — �o
n vie �F-/�c sic• Gq,,L hbY�?TYl4%147
CESSPOOLS: (cesspool must be pumped as part of ins ection locate on site la o� *5'��`fe-c r—v P )( plan) t
Number and con n:
Depth-top of liquid to inle
Depth of solids layer:
Depth of scum layer;
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegeta
PF;1 (locate on site plan)
Materials of construe
Dimensions:
h of solids;
G>. iments(note condition of soil,signs of hydraulic level of ponding,condition of vegetation,etc.);
9
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMI I'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR .
PART C
SYSTEM INFORMATION(continued)
o Property Address: 2/!✓/^/o�/S Lam/
s evdi -P
Owner: d�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. cate all Its within 00 feet.Locate where public water supply enters the building.
,�n rELtj -Cvv�A�-411 s u ��
PGS / A��«f4e t-}o21 L-5 uyas`-c t
uG
ta+vw �L 45-c -•rf �(S) 60.0''
B_Z !02'-3" C-2 .53'-t,
-G� - t3.►x `� Cs) /� - 3 3c)'- 3� , r3-3 15'9'� c-3 39'-7''
t—(-- c g (-J 4 P�-r- (F- A. - 4. 3 6 f- 5'` ) f3 -4 7 2!-4" -C 45 r Of.-
LLB c i+ (,.l f: f l --Ft L-: (S A-- S 6 3' a`' l fj-,57 44-4' � 34'•
Z®
N ell
f f •
TBf,+f✓ W a� tt �6"
1•s•.`«
•
• 'S m
r
Page 11 of I i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS111 rS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE CTION FOI•
PART C
SYSTEM I/NFORMATION(continued)
Property Address: tl 21 G,�r•�pRr/SFt �N
Owner:
Date of Inspection: io-/S-02
SITE EXAM .
`Slope
Surface water AIoff
Check cellar 02-y�
Shallow wells 1 Xt1_
Estimated depth to ground water!/ci feet
Please indicate(check)all methods used to determine the high ground water elevation:
V Obtfined from system design plans on record-If checked,date of desgl=
iewed �=19-7�
l�bserved site(abuttiniproperty/+observation hole within 150 feet of S d Checked with local Board of Health-explain: _ _g7 soA/
Checked with local excavators,installers-(attach documentatio�t) �F c0«s
ccessed USGS database-explain:_ 2 / ,Vft .✓ ,a� GAG p f 9,2 �� '/
l� 1 a'�O 9.9
You must describe how you established the high ground water elevation: A741414"
d/✓�'/
sib 13.v _/i. = /.; , Z
o•v s=a - �� o� s.�z-r G / 3 . — �/. 5',P/3l z CZ l,Y
-tL
P-w�C R-/.S-'�✓f J�Z.
0
/f/O -IV�✓
s ✓cy17
crn�r/f'a0•,�
v
v�Ap� A?.�o,4Jf
14 o�✓`�
COMMONWEALTH OF MASSACHUSETT S
EXECUTIVE OFFICE OF ENVIRONM NXJ.6AF--AI°RS
s DEPARTMENT OF ENVIRONMEN IAIl Pi6_,TECTIO.A`�
? ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
OCT ? 4 1997
FlEAL,T" ..
WILLIAM F.WELD TOWN Cc CAkii Z-,.AELE TRUDY CORE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 21 Windrush Ln, Osterville Address of Owner: Lawrence McCarthy
Date of Inspection: 16 a-9-9 (if different)
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1689 , Centervi 1 1 e,--uA 02632
Telephone Numbers 5 0 8', 7 7 5—8 7 7 6
CERTIFICATION STATEMENT
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:
✓Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: /U ?!7
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.
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 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] YSTEM 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.
Ind cafe 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 04/25/97) Page 1 of 10
4
DEP on the World Wide Web: http:/Avww.magnet.state.ma.us/dep
a�j Printed on Recycled Paper
rw i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 Windr..ush Ln, Osterville
Owner: McCarthy
Date of Inspection: /Q—47;�7
B] YSTEM 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). Describe observations:
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
C] FU THER 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 SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 Windrush Ln, Osterville
Owner: McCarthy
Date of Inspection:
D] SYSTEM FAILS:
Y must indicate ei;,,er "Yes" or "No" as to each of the following:
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.
Yes No
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 clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 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.
�r
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] LARG SYSTEM FAILS:
You mus indicate either "Yes" or "No" as to each of the following:
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:
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)
The wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req rements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 21 Windrush Ln, Osterville
Owner: McCarthy -
Date of Inspection: /Q-- 7—cJ'
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
l/ _ 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.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding 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.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
I
i
r�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 Windrush Ln, Osterville
Owner: McCarthy -,
Date of Inspection: /'U_4)--q7
FLOW CONDITIONS
RESIDENTIAL:
Design '1'60 for S.A.S
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): /Lo
Laundry connected to system (yes or no):Xc3
Seasonal use (yes or no): A-D
Water meter readings, if available (last two (2) year usage (gpd): 1995 — 42 , 000g
Sump Pump (yes or no):A�A 1996 — 69 , 000g
Last date of occupancy:/o—4'q
COM RCIAUINDUSTRIAL:
Type of tablishment:
Design flo :_gallons/day
Grease tra present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water m ter readings, if available:
Last of occupancy:
OTHIde
(Describe)
Last of occupancy:
e
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pururl5ed as part of inspection: (yes or no)jz_o
If yes, volume pumped: gallons
Reasori for pumping:
TYPE OF YSTEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 0 17 A S
66o 77�-oA Z,
Sewage odors detected when arriving at the site: (yes or no) r
.(revised 04/25/97) Page 5 of 10
� u
,a
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21, Windrush Ln, Osterville
Owner: McCarthy
Date of Inspection: /6
BUI NG SEWER:
(Locate n site plan)
Depth low grade:
Materi of construction: _cast iron _40 PVC _other (explain)
Distan a from private water supply well or suction line
Diamet r
Comm nts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:✓
(locate on bite plan)
Depth below grade: �
Material of construction: 1/concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
1 rt
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 S
Scum thickness: S `
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: / O
How dimensions were determined: Q J A de—
Comments:
(recommendation for pumping, a�n �V 1✓L�outlet tees or baffles, depth of liquid level in relation to outlet invert, strut G
condition of inlet v✓
integrity, evidence of leakage, etc.)
Goo A/
G SE TRAP:
(locat on site plan)
Depth low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensi ns:
Scum t ckness:
Distanc from top of scum to top of outlet tee or baffle:
Distan from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Comme ts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
t integrity evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
-Property Address: 21 Windrush Ln, Osterville
Owner: McCarthy
Date of Inspection: /O 4 g �7
TIGH R HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate o site plan)
Depth bel w grade:
Material o construction: _concrete rmetal _Fiberglass _Polyethylene —other(explain)
Dimen ons:
Capac : gallons
. Desi flow: gallons/day
Alarm I vel: Alarm in working order_Yes; _ No
Date of revious pumping:
Commen :
(conditio 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 box, etc.)---6
PUMP CH BER:_
(locate on si a plan)
Pumps in rking order: (Yes or No)
Alarms in orking order (Yes or No)
Commen
(note co ition of pump chamber, condition of pumps and appurtenances, etc.)
(zeviaed 04/25/97) Page 7 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21 Windrush Ln, Osterville
Owner: McCarthy
Date of Inspection:
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: 9--.
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CES OOlS: _
(local on site plan)
Num r and configuration:
Depth- p of liquid to inlet invert:
Depth f solids layer:
Depth f scum layer:
Dimen ions of cesspool:
Mater' Is of construction:
Indic Lion of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comment
(note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY-
/Y._
(locat on site plan)
Materia of construction: Dimensions:
Depth o solids:
Co I s:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
Property Address: 21 'Windrush Ln, Osterville
Owner: McCarthy
{ Date of Inspection: /b t`j 41 7
i
i SKETCH OF SEWAGE DISPOSAL SYSTEM:
1 include ties to at least two permanent references landmarks or benchmarks
Jlocate all wells within 100' (Locate where public water supply comes into house)
3
t 6 �
7
{ L�
f
.i;
t '
E
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21 Windrush Ln, Osterville
Owner: McCarthy
Date of Inspection: /O g 7
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
4
Check pumping records
i Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Tom=S Hs l if 3 a 2 6 A j c�/,'s y�-�•� ,3n da'
(zeviaed 04/25/97) Page 10 of 10
10-22-1997 04:19PN CENT OST FIREDEPT 5087902385 P.02
loons o�',u.,ouVu w WQCI "'tC ucpartmenr.
Fire Department retains original application and issues duplicate as Permit.
APPLICATION and PERMI
T Fee:—10.00
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
oq3 . o
Tank Owner Name(please print) Larry McCarthy X
59netare ,sp pror7ermrt
Address 21 Windrush Lane, Osterville, MA 02655
Srrosr G'ry Snra LO
Removal • -
Company Name Advanced Environmental Co.or Individual Advanced Environmental
Pnnl
Address P 0 Bow 472, S. Dennis MA Address
Prim
rMt
Signature (if applying fcr permit) Signature(if applying for permit)
IFCI Certifies Other i IFCI Certified LSP 4 Other
Tank Location 21 Windrush Lane, Osterville, MA 02655
Sew Addim
Tank Capacity(gallons) il 7-5 So0 Substance Last Stored #2 Fuel Oil
Tank Dimensions(diameter x length) rw r
Remarks:
will
., '....
Firm transporting waste Cyn Oil State Lic.#
Hazardous waste manifes-' E.P.A. #
Approved tank disposal yard J.G. Grant Tank yard# 03501
Type of inert gas Tank yard address Readville, MA
Cityor Town Centerville 01920
FDID# Permit#
Date of issue October 22, 1997 Date of expiration November 5, 1997
Dig safe approval number. 974203794 i Safe oll Fr el, ,umber-800-322-4844
Signature/Title of Officer ganting permit
After removal(s)send Form=?-290R signed by Local Fire Dept. to UST Regulatory Compiiance Unit. One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
1<5 ,q '- /k
FP-292(revised 9i96) /
TOTAL P.02
-z,
TOWN OF BARNSTABLE'
IfA (9
UNDERGROUND FUEL AND CHEMICAL STO MS VA �J
ASSESSORS MAP NO. �'7�9/�70 0f 0f7PARCE NO.Fo �� 0 G
ADDRESS,'�.0 WINORVw lr VILLAGE: OS/ C (0-:�
j
NAME 1-•U.Q.
CONTACT PERSON to WR ell ek/�- �4 16 Iif .PHONE NUMBER V-2 7 T
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: LEAK
OR CHEMICALS DETECTION
CAL. 7S4uc-1 SYSTEM!
DATE OF PURCHASE OF.. EACH: 1. 2. 3. 4. 5.
DATE OF FIRE,DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS '
PLEASE PROVIDE A SKETCH.SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
I
�-���5 ���1��
i
� �� n1�►� ��� '�
�.
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CENTERVIL!E OSTERVILLE MARSTONS MILLS.FIRE DISTRICT
UNDERGROUND/TANK REGISTRY PROGRAM _
Owner of Property: ���4 Date of Installation: S
Address.- •2� �--� dr v S 4
Description: 4 �e e I - Installer:
Size: S D U Certification:
Location of Tank:
.INSPECTION INFORMATION DATE COMPLETED BY
__.......__.._., Site Inspection
Air Test on Tank—Above Ground
Air Test on Tank—Within Hole
Test on Piping
Cathodic Protection Test
Continuous Monitoring System Type
Backfill Operations
Vent and Fill Pipes
Other:
' 1
I
'Tic nr ,Y,
w;
•
TESTING OF TANKS AND PIPING: EXISTING TANKS
10th 15th
13th 2 17th 20th
21 st 22nd I? o 0 0 23rd
24th o 'a -25th a 3 -26th
27th 28th . 06 29th o,7
(30).—Removal
NEW TANKS:
15th 20th — 22nd
24th 26th — 28th
(30) Removal.
Remarks:
. I i7 The insta,ation shall cal mply with the State Environmental Code Title V and Town o. }
B'vard of Health Pc uiations.,
��• .- O � 2) TI,e septic system as proposed art this plan shall not be installed until a licensed town installer LOW
ft� Y
OVIEZZ ' } tt✓ A,�. r_e es approval•.nd an installation permit from the applicabie town.
-` Prior to installation,the installer serail+verify the location oilutilities,sewer inverts, sewer lines
r,,.r' L 7! i existing septic components p;or to installations.
:
_
a 6)4 X/ � ,� ` /y'7 J �- j Ali gravity sewer piping is to be 4incl schedule ao PVC at 1/8"per fact. The first z feet out of
- -- the distribution box shall be level. All Dieing connections to be glum.
—�
(,C��m"/ � y� � `�' This septic design ular.is not to be utilized for property line deterrniiiatic+n. car for any other
R, A l 1z ,
purpose other tht n the proposed septic system Installation.
�l,44" —, �/ �,U -O AF1 Tale V cormpo►cents are to meet Title V specifications.
E � ,p �( i Parking shall be prohibited over Tale V components unless c rmpooents are H20loaded.
L+CCAT1014 '? :I ' 8f The existing leaching or cesspoois shall be pumped and filled with material per Title V
abandonment procedures Leaching and cesspool(s)and contaminated soils within the
1 ; proposed SAS shall be removed and replaced with clears sand per Title V specifications.
�0 9) Septic components are to be 10�from a water service Gne.Sewer Sines crossing a water line 5ha1i
{, be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water servici-
line or the septic line can N�sleeved uHh the sleeve being a distance of '_ on both sides of
t:rossing the line-
-- 1 3 if a garbage grinder exists in Cf rE strur,ture, it is to be removed if the septic, system is not
-- — designed to accommodate a garbage gender.
e / 111 The installer is responsible for car.
i :tf excavation around ail utilities cin the property and
3 _ - ---.-_-- ��� ����� protecting the structural integrity es all structures during the installation process of the septic
! �+tr-zc system.
-,�� Af M 12, This plan only seprespo.s that a septic.. system can he instali._ti on the praf7.rty meeting Title
requirements.
"" --- The property owner shall :eview design criteria to approve tE a total nt mbsr pf bedrooms anti
? •` y \ resign flow.installation of the septic system as proposed and mceipt of payment for the design
shall be deemed approval of the design criteria by the property owner of agent of.
i', Tne validity of this plan sl ali expire with the expiration of the town,installation permit issued lci
�t i - Lhis plan or the validity of this plait shall expire on the expiration of the Certificate of Compliance .
�� �1 IVA issued for the iiistallai ::!`-o fill_' flil`�l{��.ed sysreir en i1is�ldl�.
t� \
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TED
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i ��j.i DAVID y .
1�1 ' Dt7 = ��, MASON
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C— 0 Vr^fire
60
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ITE N , LA
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