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Home My WebLink About0043 CARLISLE DRIVE - Health 43 Carfisile Drive Marstons Mills A = PZ �2, - Is c i iy. Town of Barnstable Barnstable °F SHE T°�y Regulatory Services Department M�Ame"aC 1 �# BARNMASS. � STABLE, , public Health Division I �m 9 MASS. � Arf°MAC A 200 Main Street, Hyannis MA 02601 2007 Of_ice: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2850 9170 May 30, 2013 Florence Kacoyanis & Joyce K Smiley % Joyce K Smiley TR 43 Carlisle Drive Osterville, MA 02655 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 43 Carlisile Drive, Marstons Mills, MA was last inspected on 510312013 by Patrick O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Liquid level was found at bottom of outlet invert. • Observed solids on top of outlet baffle indicating surcharge and hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\43 Carlisle Dr MM May2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=7782 !? N' � 9 _ �yk ttAS$ u z Logged In As: Parcel Detail Wednesday' May 29 2013 Parcel Lookuu Parcel Info Parcel ID 122-155 Developer LOT 41 I Lot Location 43 CARLISLE DRIVE I Pri Frontage 1125 I Sec Road j� Sec FrontageI 1 Village 1MARSTONS MILLS + Fire District C-O-MM Town sewer exists at this address CNO Road Index§0248 Asbuilt Septic Scan: Interactive 1221551 Map l � " x#' Owner Info OwnerKACOYANIS, FLORENCE&SMILEY,JOYCE K Co-owner'%SMILEY, JOYCE K TR I Streets FLORENCE KACOYANIS LIVING.TRUS f Street2 i43 CARLISLE DRIVE City OSTERVILLE State MA Zip 02655 _____ Country Land Info Acres I0.46 use Single Fam MDL-01 ) Zoning RF Nghbd 0105 Topography�eves Road Paved � I Utilities ISeptic,Gas,Public Water ( Location F i Construction Info Building 1 of 1 Year Roof .__. Ext' Built 11979 struct Gable/Hip I Wall!Wood Shingle J Living 1 1460 Roof As h/F GIsICm ac None Area Cover p p Type i ._ ..�..._., Rooms -- r Style Ranch wall Drywall 13 Bedrooms h Model lResidential I n t Carpet Bath 2 Full Floor Rooms __.__ ._ ..._ Heat .. Total - —_ 4a4 " Grade jAverage Type IHot Water Rooms Rooms Pm stories 1 Story Heat EGa� I Found Typical Fuel�s�o._! ation Gross 3728 ' Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=7782 5/29/2013 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;e 43 Carlisle Drive Property Address '— Joyce Smiley Owner Owners Name information is required for � MA 02655 every page. City/Town May 3, 2013 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: A. General Information When filling out forms on the I computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell to cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name gad 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the ;.!spection. 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 16.340 of Title 5(310 CMR 15.000). The system.- 0 Passes ❑ Conditionally Passes ® Fails ❑ ds Further Evaluation by the Local Approving Authority May 3, 2013 Job# 13-31 Ins tor's Signature Date The system inspector shall submit a copy of this inspection report to the Ap,xoving 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. 15ins•3/13 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 43 Carlisle Drive Property Address Joyce Smiley Owner owners Name information is required for Ostervll'le Mat 02655 May 3, 2013 every page. Citylrown State ZipCode 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 an of the failure allure criteria described in 310 C%/lR �5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 iinspection if the existing tank is replaced with a complying septic t.:r,Ik 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:Subsur',:e Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments ents 43 Carlisle Drive Property Address Joyce Smile Owner Owner's Name information is required for Ostervllle every page. Caylrown Shale 0P 26 5 May 3, 2013 Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with 2-oard 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 it 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).- 0 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 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment: 43 Carlisle Drive Property Address Joyce Smiley Owner Owners Name information is required for Osterville every page. Cityl own — MA 02655 May 3, 2013 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) ana 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 :opy of the analysis must be attached to this form. 3. Other: I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the goound 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 available volume is less than_day flow 15ins•3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 43 Carlisle Drive Property Address Owne Joyce Smiley informationr is owners Name required for Osterville every page. Cityfrown Mae 02655 May 3, 2013 Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year .VOT 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 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 a; sent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Sec;..-)n 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 w Title 5 Official Inspection For a Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments ents M 43 Carlisle Drive Property Address Joyce Smiley Owner owners Name information is required for Cistervllle every page. Cityi I own 9 ate 026 ode 55 May 3, 2013 p Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as ..)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? Z ❑ 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? 2 ❑ 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 sr:wage 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 Informatio n 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 bedl,roms): 330 t5ins-3113 Title 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 Asse ssments 43 Carlisle Drive Property Address Joyce Smiley Owner Owners Name information is required for Osterville every page. CitylTown MA 02655May 3, 2013 State ZipCode Q,ate of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspecti-n information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No , Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Formun Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Carlisle Drive Prcperty Address Joyce Smile Owner Owner's Name information is required for Osterville every page. LAW I own Mae 02655 26 ode May 3 2013 P Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown 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) ind 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 Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System Form - Not for Form Voluntary Assessments 43 Carlisle Drive Property Address Joyce Smiley information Owner is Uwner s Name required for Ostervllle every page. City/I own Mae 02655 26 ode _May 3, 2013 P Dare of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed 5/21/79 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1' 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.): Septic Tank (locate on site plan): Depth below grade: 2" feet Material of construction: ® concrete El 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: 8.5' long x 5.2'wide- 1000 gal Sludge depth: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M 43 Carlisle Drive Property Address Joyce Smiley Owner Owners Name information is required for Osterville MA 02655 every page. City/Town State Zi Code May 3, 2013 P Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, levels as related to outlet invert, eviden. a of leakage, etc.): Liquid-levelwas-found at boftom�of ou"" t✓let_inv� bserved solids on top of outlet baffle indicating surcharge and hydraulic failure. r Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 43 Carlisle Drive Property Address Owner Joyce Smiley N information is Owners ame required for Osterville every page. City/I own M e P 02655 e May 3, 2013 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.): 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 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments s ;M 43 Carlisle Drive Property Address Joyce Smiley Owner Owners Name information is _ required for Csterville MA 02655 every page. Citylrown State Zi Code May 3, 2013 P 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 0.1 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.): Previously full to top 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-3113 Title 5 Official Inspection Form:Subsurfaua Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System For - Not for Voluntary Assessments 43 Carlisle Drive Property Address Joyce Smile Owner Owner's Name information is required for Osterville every page. CitylTown MA Z ip Code Date of Inspection 02655 May 3 2013 D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit ❑ 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 pondinr; damp soil, condition of vegetation, etc.): Leaching it in hydraulic failure, liquid level had been to top of structure. 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 (Sins•3/13 Indication of groundwater inflow [1 Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessment. 43 Carlisle Drive Property Address Joyce Smiley Owner N information is Owners ame -- required for Osterville every page. City/I own Ma Zip Code Date of inspection 02655 May 3, 2013 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.): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form Not for Voluntary Assessmer!,s 13 Carlisle Drive Property Address- ------ Owner J0Yct_§Tilev Owner's Na me .....informat'on is required for Osterville —----- MA _C �_/_r 02655 every page City/Town own May 3, 2013 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below El drawinq attached separately e e 28 2 38 38 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^ 43 Carlisle Drive Property Address Joyce Smiley Owner Owners Name information is required for Osterville every page. City/Town MA 02655 May 3, 2013 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: N/A 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: 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 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Carlisle Drive Property Address Joyce Smiley Owner information is Owners Name required for Osterville every page. City/I own MA 02655 May 3, 2013 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 LOCATION + SEWAGE PERMIT N0. VILLAGE q= 122 �S5 �5TE, V1 z L �c55 INSTA LLER'S NAME i ADDRESS John) T1,-;YoFrcl s-S�/2 0 B UlLDE R OR OWNER Plo�# DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7 � 41 LR 28`` 23 D 4 j3I