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0117 WINTERGREEN CIRCLE - Health
117 Wintergreen Circle Osterville A= 119-072 I 40 u ° ° A m , i e a ? , 0 0 " e ° a ^ u m _ o ° ^ o " yp , ° A 1 ° ° n i " i y r O F BARNSTA��.E A 7C 1.0CAIT IOI+T --/-.�-.- ----------- , VILLA s e; Il'JSTFiLI. IZ'."�NAM 8c P.1'64 I+IO SEM IC TAVI CAPAC]TY --�- T ptMMtt O FACIL y NO bPBC-DkO6N-S � �3�lIX..1(��Id(JR C)W14TIJI2 - I;I /[IT'la.TN. ...:-rcot�btrxAlIcE DATE- ..... .�.,.�.�.�. S�p�aratao¢a�c,Cwars�I3ctvteeaa des MEixittauan Adjustc�Ga puaaiSwtttet'Lble to tlicottntn df'i.rauhtn 1?niiitit� - �. fee►', 9 Pzlv�ae'�,Yt+ser Sug�ply Vfell aaacl l.ea��itag��cality �f'e�ay wells cxcs e9ta ar.vvlthin 2tlpI gat oI',le4i6wns rac4kly) Fr is«r i�ldmd a d lLoa Wng Fk aky Or:mly atedand's exist CCkm F11T11i3171:(lliy TT\ o � � ra. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................OF.........i�v�1Z01.)�_�'G�. .-_.._..._._.._.. ppliration for Uhipaii ai Workii Tomitrnrtiun ranfit Application is hereby made for a. Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at Location-Address r or Lot No. PAL- . � � nggr / 'I res j! W l � Installer Address f d' Type of Building Size Lot.....)-�1_�1__ ---_Sq. feet Dwelling—No. of Bedrooms.......... .....:........................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons............................ Showers — Cafeteria 44 d Other fi tures ••••-•-••--••----•-------------•--------------•-.........•----•----•-•-•--••-••••••-••....••-••••••-•------•-•--•------•-••••........------•---•---••-- W Design Flow..........63..........................gallons per person per day. Total daily flow___......:. J����...............gallons. 04 Septic Tank—Liquid capacity _-gallons Length.l�-_TPi... Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length............. Total leaching area....................sq. ft. Seepage Pit No..........j......... Diameter....... Depth below inlet....... ........ Total leaching area ,7,.,�,sq. ft. Z Other Distribution box (✓) Dosin tank ) ,( '-' Percolation Test Results Performed by. ? .!_ +�1�G1=... �oLt..LN.4! Date..... -_..___.... W Test Pit No. 1..... per inch Depth of Test Pit......1.?!_........ Depth to ground water----- ........... fL4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •••-••••••••-----------------•............•--•••......... ...........................1..---•_.... Description ofSoil .--2 _ !�:.4-1...l �il� tlJ. zpr SIND- V ......•--•••••••-•--•-••••••------•-•••-•-....--••---•--------------•---------•---•--•.............--••••-•-----•-•----•-----•••--••-•-•-•--_..... W x ---•-•---------------------••-•••-------------•--•-•--•---•------------••••......•---•--------------•••---••••------------------•••------•--•••-•-•-----------•••------......-••••-•----------•------ V Nature 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 TITIL- 5 of the State Sanitary Code— The and sig further agrees not to place the system in operatio u '11 Ce titi of Compliance has bee Wbo ar iealth. Signed----- ••----- •--•....................••-•-----•--••••......-- / v .. .... f aty Application Approved B ---•----- -- -•----•--•-••-•-••-- =--•-----I Datteo . ---------- Application Disapproved for the following reasons:_...--•-------------•--•---••-•-----•---------------•---------•------------------------------•---•.....-•--.._.. ----------------••••---••---•---•-----•----••-•-•--•••••---•••------•---•--•--•-•-------------•••--........•--•-•••-•--•-----••-•--•-•---•---•---•••---------•••--•-•••--•----••--------•••-----...--•--- Date Permit --------------------- Issued_....................................................... — Date No.r.`. - Fss.._..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Biipnoal Works Tontrur#inn ramit Application is hereby made for a Permit to Construct (I or Repair ( ) an Individual Sewage Disposal System at: i Location Address _ `` or Lot No. r C C t 1 `'te1✓o G IJ v i`? __i 1 i✓ ¢A-'-1 ,�� A)/U 1 ..............................................-�G� ----- -- ................... ............. ..... •......•• _ Owner Address W Installer Address 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 ( ) Q' Other fi tures •--••--••--•--------------•----•••-•--• • - •• W Design Flow......... __________________________gallons per person per day. Total daily flow.......... ................gallons. WSeptic Tank—Liquld capaclt�.:!. .___...gallons Length_/_!_P..... 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:':='rC__f_�.__sq. ft. Z Other Distribution box (✓) Dos4 tank ( ) " '-' Percolation Test Results_ Performed bytes 1.`�U �V;L f?` 1 G I�L�---••-•. Date.__. _1_JZ.1. f':.-�___............ Test Pit No. 1___�=2-:_.minutes per inch Depth of Test �it.___1Z__`________. Depth to ground water.... __43_I _--. GT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 9 ------------------------------••-•- -----••----••-•-------.........._._..--•----•--•--•----•---------------------•-------•----{._.....---••-•-•--------s---�--. "� Description of Soil------------- ---- --...-----.. t........................... 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.........................•---..__......-•---...._._.._........------•-----•-••••--••-- ................................ � d Daty . f( _t F..td---, ......Approved By.., i_-------------------- ..........i Date Application Disapproved for the following reasons---------------••------•-•------•-----------------------•---------------------------=--------------......-----•-- •---••--•-•-•-------.....•------•--•-••-...•--•••---•--•--••-...-••-•••-•...-•-----------------•----••--•.......•--•-••----•------•----•-•---•-••-----•-----••-•-----•-•-------•----------•-••---•....._ Date Permit No.--` ...._____.1_ t - Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF....................._..........................................................._... Trrtifiratr of Tontph anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...................................................................................................................................................................................................... Installer at ................................................ -----------------------------------....--- has been installed in accordance with the provisions of TITL, 5 of The State Sanitary Code as described in the zu- application for Disposal Works Construction Permit No........ _.. dated---- �)j.;; ____________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONSATISFACTORY. DATE ��. Inspector-----��-------•-----•-------•-•--------••--•-•--••-•--•--•--•••.......•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No:� } ...........................................OF..................................................................................... _=j•• 9•----.... FEE........................ Dispos at Works Tontrndion Trani# Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo....•••-•••-------••--------••-•--••••-••-•••--•-•------------------•...-•-----•----•--•--•---.------------------•-••--•---•--•---•---•-•--•-------••--•-----•--••------•----•....----•.._..-- Street as shown on the application for Disposal Works Construction Perrn>;;No `�_`tr f �__ Dated.......................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS SITE PL Q N SHEET I OF 2 SCALE: l {U ry sz o cAovr 4,0rN4,. p ,,9d v� LrcAG�4� y0•ilN It f 0 ,l'3/41)zip a t. � O To• � _ _ _ iZl�sLAh�' G�rJG, tij looQ �.AL. #CPTtL 119 L v i;: *kP 0Pi' i v , a !;� y Z WILLIAM M. 'ram, v WARWICK w N W . ti No. 19771 m d Adz . FOR REGISTERED LAND SURVEYOR ZONES PLAN REF. DATE BENCHMARK DATUM L) `mod► ? To Pam, WM. M. WARWICK 8 ASSOC., INC. DOMESTIC WATER ..SOURCE "50'10J 0 \4-J A -reg . 80X. 80/ -. NOR rH FA L MOUTH t FLOOD ZONE, N O h� lu-g p4! MASS. 02536 - (6/7) 663 -2638, t LEACHING BASIN SECTION NOT Ta SCALE Sh�c� 2 �,� Z 24 C. MH COVER EARTH F/LL BRICK AND MORTAR COURSES AS REO'D• TO BRING i 4'' COVER TO GRADE + 4 B FLOW LINE l :; 2' y"TO/' WASHED PEA SToNE FREE OF IRONS, 7 .P/PE�� FINES AND OUST IN PLACE ' is .. 6•' �. •• 3/ ' TO I%N WASHED CRUSHED STONE FREE OF OPENING WITH 4%g IRON FINE AND DUST /N PLACE (� S, S OUTER DIAMETER 7 AND 1314„ INSIDE a` DIAMETER I. CONCRETE TO BE 4000 PSI 26 DAYS 2. REINFORCED WITH 6%6" NO 6 .GA.:W.W.M. 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR, GREATER DEPTH REQUIREMENTS 40" 2'- ---6'0" z'-� 4. NUMBER OF PITS REQUIRED a rJ� MIN. 1 NOTE: EXCAVATE, TO ELEVATION 37•5 OR �— EFFECTIVE DIAMETER T+ 6 (Nor ro EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED .TO REMOVE ALL ` - WATER TABLE LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TVP/CAL PROF/LE GRAVEL TO DESIGNED GRADE. ��'• 5a 19°STD. LT. WGL C.l.MH COVER 4"C./.PIPE 4"81r FIBER PIPE OUTLET LEVEL O TIGHT JOINT DWELLING _ fLFLOW LINE o TO FIRST JOINT -—L �.:-•' a /4;, OO 1 10 00 Is L�.I S 119 00 if C.I. TEE a7�3 tie 000I00 1 1 1 I : ttIt000 001111 , q'A•O sig�p T0. PRECAST CONC. q$OD /Sp T BOX TO BE �}7 EJD ; I t 0 0 00 00 01 I I ., �DDOGAL.SEPTIC TANK. INSTALLED ON LEVEL,, STABLE BASE t t 1000 00 D,1 I \SEPT/C TANK TO BE t if 600 00 1 i t I INSTALL D ON LEVEL t if 100 0 , 1 1 ' . i11 (,00 000111 STABLE BASE. 0 BASIN t 1 I 0 0 0 I 0 0 1 1 i 1 (EACH/N t 1 1 0 o 0 00 0 1 BASE TO BE LEVEL t $1 00 0 1 1 i {�iLC� SOIL AND PERC. DATA PERC. RATE. �'Z MIN. /IN. 0„ TEST PIT NO. I 0 TEST PIT NO..2 tP/ASV F3 90 t V TEST BY WITNESSED. BY e:�aA-id kA�v. TEST PIT GR. EL.- DATE: l 0 2 �b I�' EL. • u o �t�.►R wATF-{�- 37 y . DESIGN DATA GENERAL NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL N°Ni SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL''2�GPD• PRECAST REINFORCED CONCRETE,UNITS. SEPTIC TANK ooD GAL: ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE. TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREA Z.._y GAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE,SUBSURFACE DISPOSAL OF BOTTOM AREA+I•�GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON .JULY 11 1977. LEACHING 'REQUIRED 1�9 I SQ.FT., ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD 'I ACTUAL LEACHING AREA OF HEALTH. z_ 250.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE . . . BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. i PITCH ALL SEWER LINES I/at / FT. UNLESS INDICATED OTHERWISE, Tt t ' •�"° SEWAGE DISPOSAL SYSTEM MARTIN y�,1t L, ��(� — �o�i�iU�•d E. MORAN �� � ►�¢ L.o � 4J �Pc GI 2341i,p d SCALE AS /ND/GATED DATE ILZh - • WiM. M. WARWICK 8 ASSOC-1 INC. : 80X 801 - NORTH FAL M041 TH ` hfA SS. 02556 — (6/7)'563—2658 PROFESSIONAL ENGINEER Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,. 117 Wintergreen Cir Property Address r Gloria Monteith Owner Owner's Name information is required for every Osterville ,.,:} MA 02655 11-5-15 a page. City/Town State Zip Code Date of Inspection CA Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services i Company Name P.O. Box 73 A ► , „ r¢ Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification ,. _ 1 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 - . , t 6fl:.r... ❑ Needs Further Evaluation by the Local Approving Authority c 111-6215 Inspector's Signature r - ' 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposa S lem•Page 1 of 17 Commonwealth of Massachusetts f ' W Title 5 Official, Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is required for every Osterville MA 02655 11-5-15 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank 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): . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments. 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name , information is required for every Osteryille_ -,7 MA 02655 11-5-15 r b. page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . . , ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ' j $ . • - •'`." ' . ' t it B) System Conditionally Passes (cone): V. I t1c r.T , ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken ol�obstructed pipe(s) or due to a,broken,'settled or uneven distribution box. System will pass inspection if(with approval of Board'of Health): El ' broken pipe(sj are replaced �°❑ Y "'n N El ND (Explain below): ❑ obstruction is removed 'y ❑ 'Y ❑':We ❑ ND (Explain below): ❑ distribution box is leveled or replaced' ❑'Y ❑,N . ❑ ND (Explain below): rr rr: ❑ 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): 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 func_tionirig'in a manner which will protect public health, -safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments M 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is Osterville MA 02655 11-5-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: f ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to'a surface water`supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No 0. Backup of sewage into facility or,system component due to overloaded or El - 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection- Fo��i Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments M 117 Wintergreen Cir Property Address Gloria Monteith a e Owner Owner's Name information is Osterville ,. MA 02655 11-5-15 required for every - t. page. City/Town - State Zip Code Date of Inspection B. Certification (cont.) _ Yes -No., ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: _ ❑., :F, N. '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`suhace water supply: ` + ❑ , ,.�® ; Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® - Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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 forn.] The system is a cesspool serving a facility with a design flow of 2000gpd- } The systefm,fails.Iy ha)M determined that one or more of the above failure ❑ • ® » criteria exist as described in 310 CMR 15.303,therefore the system fails. The f ., • • , , > system owner should contact the Board of Health to determine what will be necessary to correct the failure_ E) 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 ono"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 Zbne 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. t5ins-3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts t " . Title 5 Official InspectionForm a Subsurface Sewage Disposal System Form -*Not for Voluntary Assessments M 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name " information is required for every Osterville MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: ` Yes No _ ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? 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) ® El 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? ® El Was the facility owner'(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow.Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330 r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official -Inspection Forril ` Subsurface Sewage Disposal System,Form.-Not for Voluntary Assessments:. : p. 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is .•- •, required for every Osterville - t MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection ° D. System Information .,;C Description: Number of current residents: 0 Does residence have a garbage,grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) ` Laundry system inspected? " ` k, w . • t•: ❑ Yes ® No Seasonal use? f< , ,t . i �, . , :, ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)):,, .;t,, ,,.:,• Detail: Sump pump? a;- j ❑ Yes ® No Last date of occupancy: r,.f - 10-2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: i Design flow(based on,310,CMR 15.203):';. t: _' .: 'Gallons per day(god) Basis_of design flow{seats/persons/sq.ft.; etc.):, ; Greasetrap present?.f:.L t# t f ° ; f _-, ;- ❑ Yes ❑ No Industrial waste holding tank present?- t -�.;y� _, ,; k' ' ❑ Yes,❑ No - Non-sanitary waste discharged to the Title 5 system? "` . ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is required for every Osterville MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool r ❑ Privy ❑ Shared system (yes or no) (if yes,'attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. - ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Fora a Subsurface Sewage.Disposal System Form -Not for:Voluntary Assessments ,M 117 Wintergreen Cir ,•. , Property Address Gloria Monteith r r Owner Owner's Name information is required for every Osterville MA 02655 11-5-15 s page. City(rown State Zip Code Date of Inspection „ D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ,,,;, ;, ; , • -��; 18" Depth below grade:, _, ; t: l ,+ �, �; + �!feet - Material of construction: El ® 40 PVC ''❑ other'(explain),' t ' r :ate r V s. '40 Distance from private water supply well or'suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: i 12" feet Material of construction: ® concrete '❑ metal ❑ fiberglass ❑lpolyethylene r;, ❑ other(explain) i If tank is metal, list age: years' - Is age confirmed by a Certificate of Compliance?-(attach a•copy of certificate). ;. ❑ Yes ❑ No Dimensions: � � , • � - _1000 gal 12" Sludge depth: „ t5ins-.3I13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y�< 117 Wintergreen Cir `M Property Address Gloria Monteith Owner Owner's Name information is Osterville MA 02655 11-5-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Septic Tank(cont.) • . Distance from top of sludge to bottom of outlet tee or baffle 20 rr _ Scum thickness ry 0 Err . Distance from top of scum to top of outlet tee or baffle 1 Distance from bottom of scum to bottom of outlet tee or baffle 611 How were dimensions determined? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign 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 t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection F&rn Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments °M 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is required for every Osterville MA 02655 11-5-15 y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): -:r} LIZ 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): Dimensions: Capacity: gallons, Design Flow; :,. gallons per day Alarm present: - .❑ Yes ' ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is required for every Osterville MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection F& eL Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments „+ 4qM 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is ,•. required for every Cisterville MA 02655 11-5-15 ,r page. City/Town State Zip Code Date of Inspection ` D. System Information (cont.) • Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length:- ❑ leaching fields ,.,number, dimensions: i ❑ overflow cesspool number- ❑ innovative/alternative system • ,f• �.�; .f, Type/name of technology: Comments (note condition of soil,Signs of hydraulic failure, level�of ponding, damp soil, condition of vegetation, etc.): - Leach pit in good condition and empty at inspection with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - . Title 5 Official Inspection-Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "p 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is required for every Osteryille MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' ' Subsurface Sewage Disposal System Form =Not for Voluntary Assessments, ., 117 Wintergreen Cir Property Address , Gloria Monteith Owner Owner's Name information is t required for every Ostefville -''} MA 02655 11-5-15 t ,. page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) W.t Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: .k4 ® hand-sketch in the area below ❑ drawing attached separately ' i. `} r I .� • ./.i a}'� 1 .e.. i ,r }A T S'1 wit tt r.4 4a . • , t - f. 64,4.�k. -y L t, j" . " --9 3 �y 13 _ - 0 4 e,5C YW . f - . � t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 1 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is.required for every Ostefville MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water 1 . ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: • Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments 117 Wintergreen Cir Property Address Gloria Monteith Owner Owner's Name information is required for every Osterville MA 02655 11-5-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Sur-tmary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is Osterville MA 02655 October 20, 2014 required for every ' CI !Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms I on the computer, use only the tab 1. Inspector: key to move your -- cursor-do not Jason C. Ellis use the return key. Name of Inspector J.C. Ellis Design Co. Inc. —fE Company Name P.O. Box 81 { Company Address North Eastham MA 02651 Cityrrown State Zip Code (508)240-2220 SI 3600 RS 1126 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 ❑. Nee a of n by the Local Approving Authority o y� SR C:) 0 0 TOP ELL 0 26 October 20, 2014 `- Inspecto i re �a Date 3 TER he °` a The syste e% I bmit a copy of this inspection report to the Approving Authority,(Boar of Health or D I in days of completing this inspection. If the system is a Mared system or,-4 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submitthe =_ report to the appropriate regional office of the DEP. The original should be sent t©the syste own,-eT and copies sent to the buyer, if applicable, and the approving authority. x ****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. Ila y t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 117 Wintergreen Circle Property Address - Cora Monteith Owner Owner's Name information is required for every Osterville MA 02655 October 20, 2014 Rage_-. 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: Septic s stem is in satisfacto condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. ' The septic tank 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): t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,.•'' 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA ` 02655 ° October 20, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ---_-- 4[I Pump Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection'if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑` N ❑' ND (Explain below): ❑ obstruction is remove`d ElY ❑ N ElND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 I , ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA 02655- October 20, 2014 _ page. ZWrrown ---------- - --ZIP Gode-----=--Date-ofJnspectiora ---------- B. Certification (cont.) 2. System will fail unless the Board ofr Health (and Public Water Supplier;if any) determines that the system is functioning in a manner that protects the public health, safety and environment: • ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has.a septic tank and SAS and the SAS'is within a Zone 1 of a public water, supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water.supply well". _ Method used to determine distance: '*This system passes if the well water analysis,-performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria-Applicable to All Systems: R You must indicate"Yes" or"No"to each of the following for all inspections: Yes No: El ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 'i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 117 Wintergreen Circle Property Address Cora Monteith �. Owner Owner's Name r information is required for every Osterville MA 02655 October.20, 2014 Citylrown _ _ State Zip Code _____'_Date of Inspection B. Certification (cont), -- Yes No µ ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times.pumped: 0. ❑ ® Any portion of the SAS, cesspool or privy-is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1'of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool,or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a bEP 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, I rovided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be- necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve_a facility with a design flow of 10,000 gpd to.15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No r ® 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 k system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 - a ' Commonwealth of Massachusetts - . Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is Osterville ' required for every MA 02655 October 20,2014 __--page. City/Town _ .S.tate ---------- --- 11P Cade Date-0f Inspection------- --- C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not . available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage_back up? ® ❑ Was the site inspected for signs of break out? . Z ❑ Were all systern 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'baffies 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) providedr with" ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any'of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: F 45 Number of bedrooms(design): 3 Number of bedrooms(actual): 'DESIGN flow based on`310 CMR 15'.2-03 (forexample:.110 gpd x#of bedrooms): `'330 t5ins•3/13 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17, Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments sV•'. 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osteryille ,. MA 02655 October 20,-2014 State _ZiDCode - Date of Inspe0 on _____ D. System Information w Description: T Number of current residents: 0 Does residence have a garbage grinder? �} ❑ Yes Z' No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) El Laundry system inspected? El Yes ® No Seasonal use? ® Yes ❑ No Water meter readin s,.if available last 2 ears usage '13-11 gpd, '12- 9 ( Y 9 (gpd)) 11 gpd Detail Sump pump? , ❑ Yes ® No Last date of occupancy: Summer 2014 F 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 t., 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 117 Wintergreen Circle Property Address Cora Monteith t Owner Owner's Name information is required for every Osterville MA' 02655 October 20, 2014 ---page Cityrrown -----------_._State---Zip-Code—-------- ate-of-Inspection ------.- D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): Generallnformation , Pumping Records: Source of information: Never pumped 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) ❑ 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 . El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is Osterville required for every MA 02655 . October 20, 2014, --------page_---- City/Town ------- -- .----- State.----Zip-Code----------Date-of laspedion------------- D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984- BOH Records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5' feet .Material of construction: ❑ cast iron [K 40 PVC ❑ other(explain): ' Distance from private water supply well or suction line: f101+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer is in satisfactory condition Septic Tank(locate on site plan):- Depth.below grade: 1' ' feet Material of construction: ' ® concrete ❑ metal ; ❑fiberglass , • ❑ polyethylene ❑ other(explain) Ik _ If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ` Dimensions: _ 1000 gallons I Sludge depth: 4" t5ins-3113, Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA 02655 October 20, 2014 ylrown ------------ ----- --- --State_-- Zp Code ------Date of Inspection -- ---------- D. System Information (cont.) - Septic Tank(cont.) - Distance from top of sludge to bottom of outlet tee or baffle 30" oilScum thickness Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Direct observation -measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank is in satisfactory condition -Inlet lid 12" below grade, Outlet lid,14" below grade. Liquid level at outlet invert. Not necessary to pump at this time. Inlet tee present, Outlet baffle present. t z Grease Trap (locate on site plan): Depth below grade: a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass El 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Fo,rm. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is Osteryille MA .02655 October 20 2014 required for every , -----Pa9e•----------drown ------ -- ,------ - State_ ZipInspection-------------- 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):, Depth below grade: Material of construction: ❑ concrete ❑ metal , - ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: I Capacity: ' gallons- Design Flow: gallons per day Alarm present: Y ❑ Yes ❑ No " Alarm level: Alarm in working!orde' r:. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): t ' *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official inspection Fora . • y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r p ,M 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA 02655 -' October 20, 2014 ----Pa9�---- C /Town------------_--- -- ----- -State---_Zip-Code --------Date of-Inspection__— ---- ---------- D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any' evidence of leakage into or out of box, etc.): . D-box is in satisfactory condition.—, Pump Chamber(locate on site plan): Pumps in working order. El, Yes ❑ No* Alarms in working order: E `Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and,appurtenances, etc.): .r a A "If pumps or alarms are not in working order, system is a conditional.pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): F If SAS not located,explain why: A l5iris•3/13 Title 5 Official Inspection Four:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA 02655 October 20, 2014 ____page�_________Cityrrown State Zip Code Date of Inspection_ D. System Information (cont.) 4 Type: ® leaching pits number: 1 ❑ 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.): Leach pit is in satisfactory condition- Dry at time of inspection , no staining, no evidence of failure. Pit lid 36"below grade,Bottom of pit 110" below grade. Cesspools.(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Y Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No- t5ins-3113 Title.5 Official Inspection Form:Subsurface Sewage Disposal System-Page.13 of 17 i Commonwealth of Massachusetts D. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is Osterville MA 02655 October 20 2014 required for every , age---------------- /TownDate-of InsRectioD-.-------------------_------- D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions .. r 4 Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t, t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 1 f 17 Commonwealth of Massachusetts° } Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form- Not for Voluntary Assessments' M 117 Wintergreen Circle Property Address x Cora Monteith Owner Owner's Name .. information is fi required for every Osterville MA r'•0265& October20, 2014 _-page- --_--------City/Town------.- --- -__-- =-: -State Zip-code - ` -fate oftnspectton D. System Information (cont.)' Sketch Of Sewage Disposal System: Provide a view'of the sewage disposal system, including ties to . at least two permanent reference landmarks or benchmarks. Locate all wells within.106 feet. Locate where public water supply enters the building.Check one of the boxes below: ❑ hand-sketch in the area below El drawing attached separately u ! .. . . yr• I ' + IA.) i Ll I 0 - $ I- Y' s $ c ,TA P r. '� sue« Tv,,►l� ;� 4 A G. 27.i Ltc.H -r` Zo.q 3o s' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA. 02655 October 20, 2014 H � _____CitTrrown __— . . State_ _ Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 4'+ below leach pit 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: Wm M Warwick&Assoc. 11-2-1984 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on design plan - No groundwater at 144" below grade. Groundwater conour and USGS Topo maps indicate groundwater 30'+ below grade at this site. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 117 Wintergreen Circle Property Address Cora Monteith Owner Owner's Name information is required for every Osterville MA 02655 October 20 2014 page. cltylrown„_ ...,.., ..,,.., State . Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or.attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 I Commonwealth of Massachusetts /* 0 02 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle , Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/141201.9 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information �� (Q on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. Company A Lane Co Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8/14/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 cam, Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) 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 property located at 117 Wintergreen Circle Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle , Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) - ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James & Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. ` Yes No f ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of.break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Ir Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is Osterville Ma 02655 8/14/2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): i 3. Pumping Records: 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: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: original system installed 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness • 2° Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Outlet baffle intact and in good condition I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Cisterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1x1000 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach pit was video inspected and, pit was observed with 1' standing water with no signs of past hydraulic overloading. Walls were clean with no high stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C �1 v?'(0 X 31 �3 Z 3 ' A3 39 t(o t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Wintergreen Circle Property Address James& Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. City/Town State 'Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 1 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) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation:- Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Y Commonwealth of Massachusetts s. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 117 Wintergreen Circle Property Address James & Nancy Montgomery Owner Owner's Name information is required for every Osterville Ma 02655 8/14/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18