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0088 WINTERGREEN CIRCLE - Health (2)
88 WINTERGREEN CIRCLE Osterville A = 119 - 047 '7 r f — LO C QT I O N ........... o._GE PERMIT ..lJ O.__ tj - __ . JILUNGE. — — --...- - - l —_—. S�cur 1 t�1 ST t_l..E �5=_►,i ppJl E .� . ADDRESS _ .._._ 5UILDER .5 - - tJ h.t./l� � •A D D R E S.S -- - ---- —,T ISSUED � p N-CE PERM L-7 �... . ,. • O v a I . : _5EW�, E�PERMIT _ __LOCATION __ ____ -_ _ _ ___ � _ . _ - ILL - 1hlST LLE�S_1J�►t./lE_�_AD®RESS -_- - ____-- -- - BUILDER `; )c e,j 7 ' —_ ` — — -- -- - VN-TE_ .P_ERM1T _ O-ATE _COMP_LI_ KICE V I Q V o� �'b J 04 y No.......3 f-3•.... Fia..�:' 0.0........... THE COMMONWEALTH OF MASSACHUSETTS BOARD E HEALTH (j-L .........OF........................... ........ ._:. -._...................... Apphiation -fur Ui, Vocal Workii Cnunutrurtiuu Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( 4—)—an Individual Sewage Disposal Se C, A �� � C / . %? - . `�` o`- ••••.....f •--•--•-•••--- or Lot No. ... Loc ion-Address q- Owner Address �� a ---•••-• - •-•--••-• ---------------------------------------------- ------------------- I alter Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building -_--__ -------------------- No. of persons---------------------------- Showers .( ) — Cafeteria ( ) 04 Other fix ures -•---- ----------------------- W Design Flow_____________?'10 ............................ per person per day. Total daily flow......._.3.� v._._.__-------------gallons. WSeptic Tank—Liquid capacity------------gallons Length----------------- Width................ Diameter------ --------- Depth---------------- x Disposal Trench—No- ____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet----------_......... Total leaching area__-_-_.-_-_--____sq. it. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed bY--------------------------------------------r_--....---------- -•-- Date-•-•-----••---------------------------- a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water_._------- f1 Test Pit No. 2................minutes per inch Depth of Test Pit.___________-_____-- Depth to ground water._.____._-__-_-___--__. a -----------•-------•----------------------------•----•----•-•-•--•--•-•-••-•-•--••-••••-•••••-•-•-•.................................................... -.__ O Description of Soil_______- _-_ x4-- (---------------- ------------------------------------------ --------- --------------------- ------- W ---------------- -------- --------------------------------------------------------------------------------------•---------------- -------- ------------------- UNature of Repairs or Alterations—Answer 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 riot-to place the system in operation until a Certificate of Compliance-has b n issued by the board o health q -•---1/ - --•------•----• -•---�---'-`--�-------•---•----•- to Application Approved B ---------------------- -• _/._..: / �S----__. Date Application Disapproved for the f ol. ing reasons------------ --=----•••••--------------•-------...........--•••=-•••----••_.._.._..--•••----•--••------••-_._... --•-•--•-•--•---••-•-----•---••-•---....--•-------------------•-•--..__...-----•----•---•---•-------•---•..-----------------------------•-••---. -•-----------•------------------------•--------------- d` 7 a�" Permit No-------- �� Issued '-----------------•--•- ••--•-•-••-- Date c7N No..:.'.•..:?..�/1.... Fizs..c7::..�0........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ;. ..... ' ...............OF.....f�� �e-c. r ,,... - 'C - ApVftration -fur Uhipoiittl Works Tomilriartion Puniit Application is hereby made for a Permit to Construct ( ) or Repair ( y--an Individual Sewage Disposal System at: z � ....y .....��ut t z,o = Location-Address or Lot No. Owner Aedress w :° ..�. .. - 4'-.- -----------------•-------------------.----- ---------------------- ---------------.............---.....---.----------------------------------- Inaller Aedress Q Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms.--____-_.-'�________________________-----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type cf Building _________________•---. -___ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) A' Other fixtures ---------------------------------- W Design Flow..............%--o ....................... per person per day. Total date flow..........:... ____-___-.---....gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width------\......... Diameter-------.-------- Depth---------------- x Disposal Trench—No_ ____________________ Width-------------------- Total Length_-_____-._._--__--.- Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet_____-_______._.-._- Total leaching area-.---.._-_-.-___--sq. ft. z Other Distribution bc•x ( ) Dosing tank ( ) W Percolation Test Results Performed by- ---- ------------------------------•--------------------••----•----•_.. Date--------------------------------------- i Test Pit No. 1----------------minutes per inch Depth of "rest Pit-................... Depth to ground water.._------.--._-._-.-__-- IIA Test Pit No. 2----------------minutes per inch Depth of Test Pit____________________ Depth to ground water-_.._.---__.___---__---- 9 -------------------------------------------------------- ---------•--------------------._.........-••---------•---•--••••----•--•......................... 0 Description of Soil-------- "�-------------------------------------------------------•------------------------------------------------------------------------- -------------------------- U ---------------------------------==------------------•---------------------------------------------------------•-------------------------------------------------------------------------------------. W U Nature of Repairs or Alterations—Answer when applicable______________ ----_--_-__. _- ......:._....._. Agreement: The undersignee 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 been issued by the board of,health. Signed......--••.....:........••-•---•--•-••----••----................-.................. ------ ---�-- •.... � ......... ! / -Date Application Approved BY '--f..... y_/,- � .•--••••••---•--------•••-••..................•-••-----••. Date Application Disapproved for the f ollo�ng reasons--------------------•---•-------------------------------•----•-•-•------_------•------------- .-•-------------- --------------------------•••---•••••.----•....__.....--------------•--•------------....••-•••---•----••-I------------------•----••-•---------------------••-----•---------------------------------.----- Date G. l PermitNo......... .................................. Issued............................----------------•-........ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........G.'`..:..1 -- ............OF......✓...j. .......,,.,� Tutifiratr of f0ll mViiana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired1. ( �-) b - ,j 1� / [� t insctaller` ( �, at ----------- --------- ----------------------� L.......I has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in-the application for Disposal Works Construction Permit No-------- -------------------------------- dated..... ).._......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. C DATE / o. Inspector ------------------------------------•••... THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH No.......•'�............. FEE -.. �i��>a�ttl �rk,� �,a��tr�trti�gt �rrutit Permission is hereby granted------- ................................................................ -------------------------------------------•-•---•••-....... to Construct ( ) Eor Repair ( ")—an Individual Sewage Disposal,System at No ` �... Street 7 as shown on the application for Disposal Works Construction Permit No.......... Dated--------- _. _ __. ......%..t....?.. ............................................ B Health oa of DATE.------... = -------)----t----=- .............................. •-• l FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t• Commonwealth of Massachusetts r� �r � 0 Title 5 Officialj' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter l s Owner Owner's Name information is t MA 02655 6/24/14 required for every Ostervllle page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. k Important:When A. General Information filling out forms i I on the computer, . •I' use only the tab 1. Inspector: key to move your cursor-do not James Ford I` use the return Name of Inspector key. f crab Company Name � P.O. Box 49 Company Address t r�» Osterville MA 02655 City/Town "' "- State Zip Code 508-862-9400 ' S12482 Telephone Number f License Number B. Certification y I certify that I have personally iptspected 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).They'sy stem: ® Passes ❑ Conditionally Passes ❑ Fails f '€ ❑ Needs Further valuation by the Local Approving Authority 7/2/14 Inspe is Signature Date The s em inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea h or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,060 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. 611 fill I q t5ins 3113 Title 5 Official I ViForm:Subsurface Sewage isposal System•Page 1 of 17 1 k , i Commonwealth of Mass'hdhusetts Title 5 Official Inspection Form Subsurface Sewage Disposal`;ystem Form - Not for Voluntary Assessments is 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter Owner Owner's Name c information is required for every Osterville MA 02655 6/24/14 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 I . A) System Passes: I � ® 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. s; Comments: z•: : B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The'system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "n©" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and,over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial'infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank'is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating,that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i f . l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 p, I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. ' 88 Wintergreen Circle !. ` Property Address i The estate of Eleanor Hostetter;' t Owner Owner's Name information is Osterville MA 02655 6/24/14 required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) '' L: ro ❑ Pump Chamber pumps/.alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage,backup or break out or high static water level in the distribution box due to broken or obstructedi pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): it C ` ❑ broken pipe(s)Lre replaced ❑ Y ❑ N ❑ ND (Explain below): sl ❑ obstruction is raemoved ❑ Y ❑ N, ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i i r , i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i; t ' i 4 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 4unless 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: 1. ❑ 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Y 7! i ii Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments "t 88 Wintergreen Circle Property Address The estate of Eleanor Hostette6l, Owner Owner's Name information is required for every Osterville MA 02655 6/24/14 page. CityfTown /. State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface watery supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply: ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: f� **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. i 3. Other: d ,I it !' I I. , tIV: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"c or"No" to each of the following for all inspections: Yes No . ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static Liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1K day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 S t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M A,•'r 88 Wintergreen Circle Property Address ; The estate of Eleanor Hostette(,, Owner Owner's Name information is required for every Osterville k` MA 02655 6/24/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.);: ` Yes No Required pumping more than 4 tim ❑ ® P 9 es 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.jo a surface water.supply. : :ii ❑ ® 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. i ❑ ® 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 chl in of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00b d. ❑ ® The system fails. I have determined that one or more of the above failure criteria gust 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 gpolto: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 i,� , El El the sy5tern is within 400 feet of a surface drinking water supply ❑ ❑ fhe s em 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 Il of a public water supply well If you have answered "yes".Cb Iany 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. 15ins•3/13 ! " Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Mass'athusetts Title 5 Officialr inspection Form Subsurface Sewage Disposal;,System Form - Not for Voluntary Assessments t; 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter Owner Owner's Name information is required for every Osterville F MA 02655 6/24/14 a e. City/Town/Town P 9 Y State Zip Code Date of Inspection C. Checklist t Check if the following haveV66en done. You must indicate"yes" or"no" as to each of the following: E 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 1aFge 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 thle site inspected for signs of break out? ® ❑ Were alRsystem components, excluding the SAS, located on site? ® ❑ Were t,p,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? D. A El ® Was thelfacility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The siie and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing in'ormation. For example, a plan at the Board of Health. ® ❑ Determined in the field (if,any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Informatidn': , Residential Flow Conditioias: Number of bedrooms (design).,, 3 Number of bedrooms (actual): 3 DESIGN flow based on 31dt,MR 15.203 (for example: 110 gpd x#of bedrooms): 330 lit i. t5ins-3/13 I. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t'� • Commonwealth of MassOhusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.bystem Form - Not for Voluntary Assessments _ 1. r 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter!;:; Owner Owner's Name information is required for every Osterville t . . MA 02655 6/24/14 page. City/Town l State Zip Code Date of Inspection D. System Information' , Description: ( 1, l i ' 0 Number of current residentsj'. fl .� Does residence have a garbage grinder? ❑ Yes ® No `Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this repoit.) Laundry system inspected? El Yes ® No Seasonal use? F ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavaible 4 1, ' n Sump pump? 4! ❑ Yes ® No I Last date of occupancy: A unknown Date Commercial/Industrial Flow Conditions: . Type of Establishment: g Design flow(based on 310.GMR 15.203): Gallons per day(gpd) Basis of design flow(seat 1/persons/sq.ft., etc.): Grease trap present? r El Yes ❑ No Industrial waste holding to°nk present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: { t5ins•3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 u . d; i y. Commonwealth of Massachusetts Title 5 OfficialSy Inspection Form Subsurface Sewage Disposal stem Form -Not for Voluntary Assessments a 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter Owner Owner's Name information is Osteryille t. MA 02655 6/24/14 required for every ;. ;t— page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) i- Last date of occupancy/used Date Other(describe below): i• rr_ f a t General Information �4 Pumping Records: i Source of information: unknown Was system pumped as part.of the inspection? ® Yes ❑ No 4 If yes, volume pumped: gallons i . . How was quantity pumped'determined? maintenance Reason for pumping: I Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection,of the I/A system by system operator under contract ❑ Tight tank: Attach a copy of the DEP approval. ❑ Other(describe): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 t: e. Commonwealth of Mas$ chusetts U W Title 5 Official; Inspection Fora Subsurface Sewage Disposal:System Form - Not for Voluntary Assessments 88 Wintergreen Circle Property Address v The estate of Eleanor Hostetter Owner Owner's Name information is required for every Osterville MA 02655 6/24/14 page. City/Town , State Zip Code Date of Inspection D. System Informations(Cont.) Approximate age of all components, date installed (if known) and source of information: leach pit added in 1975? Were sewage odors detected'when arriving at the site? ❑ Yes ® No ,. Y: Building Sewer(locate on'site plan): Depth below grade: y { feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water:supply well or suction Fine: feet Comments (on condition of joints, venting, evidence of leakage, etc.): • yt Septic Tank (locate on site,plan): Depth below grade: 1 feet Material of construction: ❑ concrete ❑ rrio61 ❑fiberglass ❑ polyethylene y ® other(explain) Cesspool acting as a septic 1t nk 01 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑' Yes ❑ No Dimensions: i,. Sludge depth: 2 l5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I e Commonwealth of Massachusetts Title 5 Officials inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,i. 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter Owner Owner's Name information is required for every Osteryille MA 02655 6/24/14 page. City/Town State Zip Code Date of Inspection D. System Information ;(cont.) Septic Tank (cont.) Distance from top of sludge fosbottom of outlet tee or baffle 3 Scum thickness Distance from top of scum tp top of outlet tee or baffle Distance from bottom of sc6m"to bottom of outlet tee or baffle i.. measure How were dimensions deter"pined? r Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The liquid level was even with the outlet invert. The cesspool was pumped after the inspection. i. E` (locate on site "! : Grease Trap (lo plan): Ian) Depth below grade: g.: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i; I Dimensions: > f Scum thickness IT Distance from top of scurl top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: i Date is l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I i ;i Commonwealth of Massaphusetts Title 5 Officiat." Inspection Form Subsurface Sewage Disposal:System Form - Not for Voluntary Assessments �a.�,•y'' 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter Owner Owner's Name information is required for every Osterville #' ' MA 02655 6/24/14 page. City/Town ; State Zip Code Date of Inspection D. System InformaU6hl (cons) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i � s'. ti Tight or Holding Tank(tat k:must be pumped at time of inspection) (locate on site plan): Depth below grade: G' Material of construction: ❑ concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: + if Capacity: gallons Design Flow: t% gallons per day Alarm present: .❑ Yes ❑ No _ I Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: i Date 1} _t Comments (condition of alafm and float switches, etc.): li f Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins-3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts _ Title 5 Officials Inspection Fora' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z. a 88 Wintergreen Circle Property Address _ The estate of Eleanor Hostetter Owner Owner's Name information is required for every Osterville MA 02655 6/24/14 page. City/Town ! State Zip Code Date of Inspection D. System Information ,(cont.) a Distribution Box (if preseni'must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a Comments (note if box is level;and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 1 i. t - t• r f Pump Chamber(locate on�site plan): Pumps in working order: ❑ Yes ❑ No' .t F Alarms in working order: ; : . ❑ Yes ❑ No* I� Comments (note condition of'pump chamber, condition of pumps and appurtenances, etc.): t r . t; If pumps or alarms are no{{t;inworking order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): i' Z. If SAS not located, explain!;why: n i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official rispection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments M 88 Wintergreen Circle Property Address _ The estate of Eleanor Hostetter'. Owner Owner's Name information is required for every Osterville MA 02655 6/24/14 page. CitylTown State Zip Code Date of Inspection D. System Information,(cont.) Type: t . r ® leaching pits',; ;; number: 1000 gal. with 2' stone ❑ leaching chambers number: ❑ leaching galleries number: ii. �I El leaching trer!cKe:s number, length: ❑ leaching fields i number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: t � Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The overflow cesspool had Z` of water on the bottom and the cover was 18" below. The leach pit was dry and clean. The stain line was 1' up from the bottom and the cover was 2' below. I dug down beside the pit and it was found to have 2' of stone ii. Cesspools (cesspool must beapumped as part of inspection) (locate on site plan): i Number and configuration Depth—top of liquid to inlet invert Depth of solids layer s Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow El Yes [:1 No ti (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 V ' C Commonwealth of Massa..rhusetts Title 5 Official Inspection Forma Subsurface Sewage Disposal Sy' tem Form - Not for Voluntary Assessments . 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter Owner Owner's Name information is MA 02655 6/24/14 required for every Osteryllle page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t: t' Privy (locate on site plan): Materials of construction: Dimensions , Depth of solids i Comments (note condition Of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a 1 f. 15ins-3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Mass' p:husetts Title 5 Official1 Inspection Form Subsurface Sewage Disposaf;System Form - Not for Voluntary Assessments 6�y 88 Wintergreen Circle Property Address it The estate of Eleanor Hostetter, Owner Owner's Name information is required for every Osterville MA 02655 6/24/14 page. City/Town State Zip Code Date of Inspection Do System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply 6nt*ers the building. Check one of the boxes below: l; ® hand-sketch in the area;below ❑ drawing attached separately ` �u ►p bAck Nousc . '.A .B ' 3 F` I,. CcsJfwl CALsspool i r i; S 1 A y 18 a a8 18 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i' Ii f i if .. 7 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments a °r 88 Wintergreen Circle Property Address The estate of Eleanor Hostetter.. Owner Owner's Name information is �E required for every Osterville MA 02655 6/24/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) F Site Exam: ❑ Check Slope 4 ❑ Surface water I _ ❑ Check cellar i - ❑ Shallow wells I Estimated depth to high ground water: feet Please indicate all methods'used to determine the high ground water elevation: El 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: Using topo and'water contours maps r, ❑ Checked with local excavators, installers -(attach documentation) . z El Accessed USG! database-explain: You must describe how yod established the high ground water elevation: see above G • Before filing this InspectimnReport, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 tt; t , r Commonwealth of Massachusetts Title 5 Officia ;Inspection Form Subsurface Sewage Disposal�'System Form - Not for Voluntary Assessments 88 Wintergreen Circle ['' Property Address t, The estate of Eleanor Hostetterj4 Owner Owner's Name information is r + required for every Osterville j a MA 02655 6/24/14 page. City/Town State Zip Code Date of Inspection E. Report Completen§ss Checklist U • ® Inspection Summary:A,:s;B, C, D, or E checked i . ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t'.. t .. ' i III i, I, i • o F' •C u I5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t. �.