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Home My WebLink About0165 CONCORD LANE - Health �5 Concord Lane �\ --- Marstons Mills A= 122 126 _-- COMMONWEALTH OF MASSACHUSETTS ` _ W EXECUTIVE OFFICE OF ENVIRONMENTA�Li`A�IFFAI]RS'\ � sL d DEPARTMENT OF ENVIRONMENTAL PROTflU TECT.ION,, 00 A Y O� i�qM SVey TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #165 Concord Lane Os e,MA nca�.A �i2o Owner's Name: Cathv Fox Owner's Address: #165 Concord Lane Osterville,MA j Date of Inspection: 02/23/05 Name of Inspector: (please print) Mr.Carmen E.Shay Company Name: CAPEWIDE ENTERPRISES,LLC Mailing Address: P.O.Box 763 Centerville,MA 0632 Telephone Number: (508)-428-4028 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper 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-0Fkfa XX Passes �P� 8 Conditionally Passes R1Vi�Nc o� o CA G� Need urgiq Evaluation by the Local Approving Authori E. Fails SHAY O Inspector's Signature: Date: 2/23/05 �,�FgriF�``o2 4FS IN SIP 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. Notes and Comments 3' Liquid observed in Leach Pit. ****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. Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of I 1 w OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: .„.,, 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 1I 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. Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks 9. XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up'? XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site? XX _ 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? XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no XX _ Existing information. For example,a plan at the Board of Health. XX _ 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(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: Unk. Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ ' Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None Available Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: January 1982-original,- per Owner&BOH Records Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #165 Concord Lane _ Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: cast iron _40 PVC XX other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 24"to Top of Tank Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5' deep x 5'wide by 8' long (1,000 gallons) Sludge depth: 4.0' Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: '/4 inch scum laver noted Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks, leaks or water infiltration/exfiltration 4" PVC Tee present at inlet end. Outlet baffle present and in good condition Liquid level equal with outlet invert GREASE TRAP:_(locate on site plan) Depth below grade:_ 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: 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 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan) 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 Present—one outlet,no evidence of significant carryover. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I ' Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX 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.): No evidence of hydraulic failure of septic tank or of leach either leach pit 3' Liquid observed in leach pit. Cover located and removed as part of inspection. No Riser present Top of leach pit is 42" below ground. Riser installed at time of inspection 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Swing Ties: Concord Lane A- Tank In—23.5' B- Tank In—39' A—D-Box—24.5 B—D-Box—44' Water Line A—Leach Pit —33 B—Leach Pit —52 Exist House A B Deck O O Septic Tank (1000 Gal.) D-Box Leach Pit I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4165 Concord Lane Osterville,MA Owner: Cathy Fox Date of Inspection: 02/23/05 SITE EXAM Slope Surface water - 'h mile+/- Check cellar -Yes Shallow wells—None Estimated depth to ground water 25' feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: , XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Ouadrangle of USGS Map. Per USGS MAP PLATE 2: Elev.of Ground=Elev.-56 Elev.Of Groundwater=Elev.-20 Feet Elev.Of Bottom of Leach Pit 10 Feet below grade or Elev. 46 Therefore: 46-20=26 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well SDW-253(Zone C): 3.5 feet Adjusted Groundwater Separation=46'—23.5=22.50 feet between bottom of pit and adi.groundwater Grade=Elev. 56 feet Pit#1 Septic Tank Bottom of Pit=Elev. =46 feet Adj. Groundwater=Elev.23.5 r � f Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 � . John. 'Title VS Lei j D:E. Septic I spector ,lay .O. Box 2 p� 2 ticket, MX 02536 WILLIAM F.WELD "df 1998 508)564-6813 Governor r"i. H tr 11%rggt ARGEO PAUL CELLUCCI 4pEpr f Lt.Governor an SUBSURFACE SEWAGE DISPOSAL SYSTEM I, ECTION tit 1�� PART A 8' CERTIFICATION Property Address: 165 Concord Lane Osterville Address of Owner: Date of Inspection: 4110198 (If different) Name of Inspector: John Graci Mr.Conti:138 Brookline St Watertown Ma. 02112 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria defined In Title V COndltl0 II Passes code 310CMR16303.My findings are of how the system Is y performing at the time of the Inspection.My Inspection does _ Needs F illy r Evaluation By the Local Approving Authority not impN any warranty or guarantee ofthelongevltyofthe Fails septic system and any of Its components useful life. Inspector's Signature: Date: 4123198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of — Colhpliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, Is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised M7)97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 concord Lane ostervi►re Owner: Mr.Conti:138 Brookline St Watertown Ma. 02172 Date of Inspection:4110199 _ Sewaae backup or.breakout or hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT.THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other 01 SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. pevlasd 04127l97) 1 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 165 Concord Lane Osterville Owner: Mr.Conti:138 Brookline St Watertown Ma. 02172 Date of Inspection:41101stt D]SYSTEM FAILS(continued) 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). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revleed 04117197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 105 Concord Lane osterville Owner: Mr.Conti:138 Brookline St Watertown Ma. 02172 Date of Inspection:4l101es Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x _ All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)] {revlaed 04117187I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 105 concord Lane Osterville Owner: Mr.Cond:138 Brookline at Watertown Ma. 02172 Date of Inspection:4110199 FLOW CONDITIONS RESIDENTIAL:Design flow: = g•pd./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes d Seasonal use(yes or no): Yes Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: We COMMERCIAL/INDUSTRIAL: Type of establishment: MR Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nta Last date of occupancy. Na OTHER:(Describe) rra Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rva TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: 1984 Sewage odors detected when arriving at the site:(yes or no) No (revised 01rl7)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 Concord Lane Osterville Owner: Mr.Conti:138 Brookline St Watertown Ma. 02172 Date of Inspection:4110199 SEPTIC TANK: x (locate on site plan) Depth below grade: 1'e" Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nis . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L9'6'-H5'7•'W4'10" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:a Distance from top of scum to top of outlet tee or baffle:2' Distance form bottom of scum to bottom of outlet tee or baffle:nra How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Septic tank and ell components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: We Date of last pumping, Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2' Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line o- Diameter: nla Qmments: (conditions of joints,venting,.evidence of leakage, etc.) (revlsed 007197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 Concord Lane Ostervllle Owner: Mr.Conti:138 Brookline St Watertown Ma. 02172 Date of Inspection:4110199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Capacity: rda gallons Design flow: rda gallons/day Alarm level:_la Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda l PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised042T)97) . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 165 Concord Lane osterville Owner: Mr.Conti:138 Brookline St Watertown Ma. 02172 Date of Inspection:4110199 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 1000gallon leach pit leaching chambers,number:Na leaching galleries,number: Na leaching trenches,number,length: Na leaching fields,number,dimensions:Na overflow cesspool,number:nla Alternate system: Na Name of Technology:_Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Leach pit and all components are structurally sound and functioning properly.System never had more than 2'of water In It CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: n►a Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: Ne Depth of solids: Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na (revised 04fNW) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 165 Concord Lane Osterville Mr.Conti:138 Brookline St Watertown Ma 02172 4110198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) i c �I A c K� Page ! o! 10 (revived MUST) f _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 165 Concord Lane osterville Mr.Conti:139 Brookline St Watertown Ma. 02172 4110199 Depth of groundwater 12t , Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revised04)2719T) page >f0 of 10 I rl Lq/ r/Gr ,"'''''` c3 v I Q,w r4l 3 to Tv 2 y j to 3,co V z V 3 c . Co o - j3 tv t l ` Y La O Cl _ W 3 b � G r-�w ctisS �� cot 14 2 4.1 -b ter, a � / � � Z� j +,''`t1 � �.' �� x` o� � �� -`�� Q _ _ ®�_ C`�� b� .u. - �� n __ �� o��f ,� � u�� 10S- TOWN OF BARNSTABLE LOCATION-- c— cC\ L4• SEWAGE # VILLAGE_ ASSESSOR'S MAP & LOT Z2 4 INSTALLER'S AME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) WY Co' (size) 11 AGO GQ\\(X\ NO.' OF BEDROOMS 3 n BUILDER OR OWNER U PERMTTDATE: C Z I- ►'L COMPLIANCE DATE:-- Separation Distance Between the: Maximum.Adjusted Groundwater Table and Bottom of Leaching Facility 2 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leac 'ng Facility(If etlands exist within 300 feet of lea facility) td,6 Feet Furnished by r O-q In � Lb CAT ION � SEWAGE PERMIT NO. _V,,I'L L A G E Y� INSTA LLER'S NAME i ADDRESS d U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED / �� '��_ � � �� Shy, � ,� _ _, .2.3�� !i �3:�' �/ Zp Y � - Fizi3 ?.f................ THE%COMMONWEALTH OF. MASSACHUSETTS BOAR® OF HEALTH ......................................--.O F............................._...........------.-----------._...------.........._....... Applira#iun for Disposal Works Tonstrnrtiun throb# Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at .. - L io -Address or Lot No. -- ..� Owner Address a .......... ----------- -------.---.....-------------.....--------- Installer Address Type of Building Size Lot_z 4,0.1.3....Sq. feet Dwelling—No. of Bedrooms.............�.........__..__.__......Expansion Attic ( ) Garbage Grinder (NO) a'4 Other—Type of Building _..... No. of persons............................ Showers YP g ---------------------- P ( --->--- Cafeteria ( ) dOther fixtures .------•----•-- •----•••.............•-••••-••••--•-------•-•••-•••--•--------------------••-•••••••••••. W Design Flow.......... .....................gallons per person per day. Total daily flow.........&......0....................gallons. WSeptic Tank—Liquid'capacity__----_-____gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width_. ........ area....................sq.------- Seepage Depth below inlet..... Total leaching area P� � P g =2 1V-----sq. tt. Z Other Distribution box ( ) Dosing tank ( Percolation Test Results Performed by. A_ �n k..4.Nv,6.AJ ....... . 2-7—�� _P._ _••-•••_.... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................niinutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --••••••-•-•-----------••---•---••--•----------------------••------------•--•--••--------------.-----------------------•---------------------------------•--- O Description of Soil.................................................................... . ----------------------------------------- -- -- -- - x .....................................................1 f - .......... '4466------------------------------------- ------------------- V W UNature of'Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------------------•-----------------------------------.........-----------•-------------------------------------------------------------------------------•----•....•..... Agreement: The undersigned agrees to install the aforedescrib Individual Sewage Disposal System ' accordance with the provisions of TITL i� 5 of the State Sanitary Code The nders' n further agrees not ace the system in operation until a Certificate of Compliance has bee sued e b r Signe ... ... . . .................................................. ••... ... ................................ Date Application Approved By........... _...... i Date Application Disapproved for the following reasons:.......................................................................................... -----------._ ---------------------•------......-----------•••-••-•--•-••--•••-------•------••----•••---------- ------------------------------------------ Date PermitNo......................................................... Issued....................................................... Date ` r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... __..........OF......................................................................................... ., Appliration for Uiipoiittl Workii Tontrurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....pp ...........•--..__.... -..... .h^�....... •.......-•....................•------.•---- •••--•----.....--•---...............•----- ... --•-- --•• . Loo �A�d.. -- •--.....-.---•------------•-•----•--•-••-.---Lot No. Owner I Address w ,4 ey----------------------------------------•--------- ------------------------............------. ........................................... Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures - d . W Design Flow............................:...............gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___.._......_.......sq. ft. x Seepage Pit No-------------_------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - aPercolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ---•-•----••-----•---••-••••---•----••-•-------•----•--------••---•.............•-•----...-•----•--•......................................................... 0 Description of Soil....................................................................---•----------------------------------------- ................ ................................ x U ----•-----------•---•-•-----••--•--•-••-----•••---------•.......................•••---.........•-------•-••-•-------------••--•-••--••--•--•-------•................................................... ---------------------------------------------------------------------------------------------------- ------------------------------------------------------------ -------------------------------------- V Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. -------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------.................-•--- Agreement: The undersigned agrees to install the aforedescrib9ty Individual Sewage Disposal System ' accordance with the provisions of TITLE 5 of the State Sanitary Code Th nders' ne f ther agrees not ce the system in operation until a Certificate of Compliance has bee ued e b -� Signe ..•..-- • .............................................••. --•--- •--- ......................... Date Application Approved By............ = ------ --- ---- Date Application Disapproved for the following reasons:................................................................................................................ ..............•-•......•--------•-----•••----•-•----••-•--------•-•••-•••.....---------------------•--......-----------•-•--•---- -------•-...............-----------•------......... -----......._. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tnrtifiratr of Tontlilianrr THIS IS TO CERTIFY, hat theIdividual Sewage Disposal System constructed ( ) or Repaired ( ) by........:......................................... C = _._....----•-----------•-•-------------•--..__...... ---••-.........••---•------.................----...._.._..--..-- Installer�+'},_ att.-•----- A....-�t----------------- has been installed in accordance with the provisions of TIT, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..__ __.�............ "`...._...... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RUE® A GUARANTEE THAT THE SYSTEM WILYPNCTION SATISFACTORY. DATE.... // ...................................................... Insp •. ---- ----------------------------------------------•--••-------------•..... THE COMMONWEALTH SSACHUSETTS BOARD OF HEALTH �r OF........................................................................_............ No.. f .-. ?.............�/L L FED.............•-----..... Disposal Workii 01honitrnrtion pumit Permission is hereby granted...........,f/C.!' ------•-•--.-------------•-----------------•-----------------------•--........--------........--•--........ to ConstrtLct_j 6<or Repair ( ) an dividual Sewage Disposal Syst,%m at No........ ----...--_.� u..l.. ....., ------------- Street as shown on the application for Disposal Works Construction Permit No.._.....__.. �v -•------- Dated.. .............. DATE.....................................fly _••• Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS StW 6LG- FAMILs? - gE09-00M NO GARBAGE 6QjwDE2. DAtLY .FLOW : 110K 3 = a30' Pp Sir SEPTIG TAkiK = 330XI5oS/. �o u5E- 1 000 - 015Po5AL PIT U5E 1000 GAI-• 5%DG.WALL A2EA = 1 50 6A 150 6A. x 50TTOM AREAr • Yo 5,F• _p20? 5O G.PC�_ PIT -To-rAL DAILY 330 G.PO PE2CoLATtoN RATES I"IN ?-PAIN 1K Of .y. .'AL N. *26�of S` i to i#CHARDA. JOIN 00, G r i BAXTEf3 Na 24048 a S T� q Co 4Dsu • ToP FNDa'Sl FG=� �� I I, i �; ^ Nv 7 b c. l.I 1000 lN�• 'St1FS�iWL DtST. INd. GA4 . S�` ScPTIL 'L 1000 INS! BoX TANK I1 LEacu�I INV. INV. I� PIT St•Z SS.d- I' I WITIA , IWASu1:D 6T0mD- a_ � -••+1�.— � --� �— is C�RTIFIso pLoT PII �r PR.OFILG d o t A-T 10 4 (2 hl0 SCALE ScAt_t: III Go VA-I— przo?0 5 tav p L p.W RE F 6 iZEt4 GE 1 GERTtFY -rNAT T1+E 14ovd; 5uowN I GO - �( i NSR6 0►�,1 N�PL`(5 WITH•T NE S 1 DS;LIN E A W 0 56TBAC,V, 9-E.00tR.eAENT> of •TIDE -TvwN or- IS ISOT- LOCP.TED •WITNIW T S Gl. 00 PLAIN I�� IL 3ZCo pG • �I ct . q 6AIcTE2.e WY6 INC. K.EG I SZ 1cQErV'I.Aw o•5 u R•v wfQz S Tu15 PI-�.►�! I�i No*T' gn�jF,p pa AN os•rE2VILLE • Ss• INSTRuM6N1' Su2vGY �•TNE Dt=tr'SET�j Suout� (, �. NoT DC. V>C'•DTd pCT��'-MI►-I�, t_.c�T �-1'-IE�� APP�.IGA►JT• ��' �� -�•-