HomeMy WebLinkAbout3-17 LOUISBURG SQUARE - HYANNIS CONDOS 3-17 Louisburg Square (Bld',,, s)
Center Village
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owners Name
information is P.O. Box 340 Marstons Mills, MA 02648 05/11/12
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector: O
key to move your p
cursor-do not Paul W. Davis
use the return Name of Inspector
key.
Rosano Davis Sanitary Pumping, Inc.
Company Name
9 Rocky Lane
Company Address
Cohasset MA 02025
Cityrrown State Zip Code
781-383-8888 S149
Telephone Number License Number
LU B. Certification
per-- = I certifythat 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 pertormed based on my training and experience in the proper function and maintenance of on site
=..s sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
`'-- - Title 5,1(310 CMR 16.000).The system:
r� Passes [I Conditionally Passes El Fails
❑ Needs Further Evaluation by the Local Approving Authority
/ 05/16/12
Inspector's Tignature 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-11/10 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
M 5 Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is P.O. Box 340, Marstons Mills, MA 02648 05/11/12
required for every
page. CityrFown 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:
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05/11112
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 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):
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
t5ins•11/10 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 Assessments
Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owners Name
information is P.O. Box 340 Marstons Mills, MA 02648 05/11/12
required for every
State Zip Code Date of Inspection
page. City/Town
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface 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:
,J
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is P.O. Box 340 Marstons A 02648 05/11/12
required for every � Mills,�
page. Cityrrown 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:
❑ ® 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 absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No .
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05/11/12
page. Cityrrown 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?
❑ ® 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual): 16 units.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is P.O. Box 340 Marstons Mills, MA 02648 06/11/12
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
19 on
Number of current residents: average.
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ® Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Water meter readings were not available at time of inspection.
Sump pump? ® Yes ❑ No
Last date of occupancy: Dates occupied.
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•11/10 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
-17 Louisburg Square, Hyannis,
M Center Village: 3 q MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05/11/12
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: Property currently under regular maintenance
schedule.Tank was pumped on 04/10/12.
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
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 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
M Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is
required for every P.O. Box 340, Marstons Mills, MA 02648 05/11/12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
39 years per previous inspection.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 54"
p g feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain): 4"cast iron inlet pipe.
Distance from private water supply well or suction line: No known wells in immediate
area.
Comments(on condition of joints, venting, evidence of leakage, etc.):
Inlet pipe appeared to be clean and flowing freely. No evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade: 39"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
2,000-gallon precast concrete septic tank.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 6'wide X 5'deep X II' long.
3„ I
Sludge depth:
t5ins•11/10 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
Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05/11112
page. Cityrfown 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 A-100 Zabel filter in place.
0..
Scum thickness
Distance from top of scum to top of outlet tee or baffle A-100 Zabel filter in place.
Distance from bottom of scum to bottom of outlet tee or baffle A-100 Zabel filter in place.
How were dimensions determined? Measured with a 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.):
Cast iron inlet tee and A-100 Zabel effluent filter in place.Tank was structurally sound and
watertight and all effluent levels were at an appropriate height.There are no repairs
recommended at this time.
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•11/10 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 Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05/11/12
page. Cityrrown 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.):
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: bate
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 or 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05111/12
page. Cityrrown 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.):
Box was structurally sound and watertight and providing even distribution of effluent.
Carryover was moderate.There are no repairs recommended at this time.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form: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 Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340 Marstons Mills, MA 02648 05/11/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2-8'X 6'
leaching pits.
❑ 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.):
There was no surface wetness or breakout observed.There were no signs of hydraulic failure
observed. Both pits had appropriate effluent levels. SAS appeared to be in proper working
order.There are no repairs recommended at this time.
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
I Dimensions of cesspool
III Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is P.O. Box 340 Marstons Mills,
required for every � MA 02648 05111/12
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is .required for every �
p O. Box 340 Marstons Mills, MA 02648 05/11/12
page. City(rown 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:
® hand-sketch in the area below
❑ drawing attached separately
p ..
—. W —
o 517 rear
A �
,v
A _D 19: 6 `
x 6- E = 44
A - F = 44
i=- 30 �
/0 CC& �Bvi lr� 5
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Center Village: 3-17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340, Marstons Mills, MA 02648 05111/12
page. Citylrown 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: SEE BELOW
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:
Previous Title 5 Inspections.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
During previous inspections the high groundwater was indicated to be 19'-7" below grade.
Clearly there is separation from the bottom of the SAS to the high groundwater elevation. It
was by this non-intrusive method that it was estimated that separation exists from the bottom
of the SAS and the high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Forth: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
M Center Village: 3 -17 Louisburg Square, Hyannis, MA BUILDING 5
Property Address
Multiple Owners: Huntingest Property Management
Owner Owner's Name
information is required for every P.O. Box 340 Marstons Mills MA 02648 05/11/12
page. Citylfown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
KINLIN GROVER
GMAC REAL ESTATE
Robert B.Kinlin Paul E.Grover
bkinlin@kinlingrover.com pgrover@kinlingrover.com
November 1, 2006
Ms. Donna Z. Miorandi
C/o Town of Barnstable Public Health Division
200 Main Street
Hyannis,MA 02601
Dear Donna:
In response to the October 11, 2006 board of health inspection done at the condo I own at
48 Captain Cook Lane in Centerville, I wanted to inform you that I have addressed the three
issues that were outlined.
The downspouts have been extended three feet beyond the back of the building;the dryer
vent has been fixed so it is now properly vented and the first floor vent fan in the bathroom
has been cleaned and inspected to ensure it runs properly.
If you have any questions,please feel free to call me at 508.364.3500.
Sincerely,
Paul E. Grover
/mw
u
Four Wianno Avenue,Osterville,MA 02655
Tel:508.420.1130 Fax:508.420.7114 Toll Free:866.420.1130 Website:www.capefinehomes.com
OVEN1441W1.31
■ Complete items 1,2,and 3.Also complete A. Signs ure
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PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE '
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Hyannis,MA 02601
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important Reminders:
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01
k kQ1 A& 011
M THE COMMONWEALTH OF MASSACHUSETTS
{� FOF&3 &W HOBBS&WARREN
ROA"RD OF HEALTH _
j C TY/TOWN'
'DEP MENT ; I At `
'o ADDRESS
�e ���^'` 7 f�TELEPHONE "�,,e�
r3 P nA s! k tt _
Address ' ` _ P' _ _ f )cc ant
Q o Floor Apartment No. No.of Occupnts — .y
No. of Habitable Rooms No.Sleeping Rooms
No. dwelling or rooming units N�o,.�Stories j ^~I,AAP X//Name
and address of owner t >. J , f
Remarks Reg. Vio.
YARD Out Bld s.: Fences: t
Garbage and Rubbish
-' Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows: ,-
Roof fi
Gutters, Drains:
w, 1
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
.HEATING Chimneys: _.
Central VY ❑ N E ui . Repair
TYPE: Stacks, Flues,Vents �r Z V _hrf I A/ 'I'`''.. ;,
PLUMBING: Su._. ,I L-ine: . � �* � ' I �, )1A �`J* 'k,
❑ MS ❑ ST ❑ P -Waste-Lines
H.W.Tanks Safetyand Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box.-
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom XY
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect..-
Stacks, Flues,Vents,Safeties.-
Kitchen Facilities Sink
Stove 'Al
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n. IV
Wash Basin;Shower or Tub:V ,t j
Infestation Rats, Mice, Roaches or Other. ` " � � " ,,
Egress Dual and Obst'n: NA"I" r�-
General Building Posted '
Locks on Doors
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
' OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS,,SIG_NED AND CERTIFIED UNDER THE PAINS AND
PENALTIESOFPERJURY " ;� .
ffj f`/ 4 3
INSPECTOR/ t t F' 7 k tjITLE
DATE 0 r' r7 , �' 'r TIME ,'"P M
r s A.M.
THE NEXT SCHEDULED REINSPECTION A' ," � .1`!�_ P.M.
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410.750: Conditions Deemed to Endanger or Impair Health or Safety
xi in residential r mises shall be deemed conditions which may endanger or
The following conditions, when found toe existpe y g
9
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
n
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
r
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
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ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025E� ;
(781)383-1234 (781)545-2800 (781)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSNaTSr`1
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION - ---- ---
Property Address 3- 17 Louisburg Square 141
`Building 5 f
Center Village,Hyannis,MA
Owner's Name Multiple Owners
Owner's Address Huntingest Property Management
40 Industry Road—P.O.Box 340 -��
Marstons Mills,MA 02648
Date of Inspection Completed 1/19/06
Name of Inspector Jeffrey F.O'Connell
Company Name Rosano Davis Sanitary Pumping,Inc.
Mailing Address . 9 Rocky Lane
Cohasset,MA 02025
Telephone Number 781-383-1234
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:
®Passes
❑Conditionally Passes
❑Needs Further Evaluation by the Local Approving Authority
❑Fails
Inspector's Signature: Date: 02/02/06
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty
(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector
and the system owner shall submit the report to the appropriate regional office of the 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:
****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.
1
Title 5 Inspection Form 6/15/2000
r..
i
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
INSPECTION SUMMARY: Check A,B,C,D or E/AL WAYS complete all of section D:
A] SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.3(
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.
Indicate 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 breakout 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. The system will pass inspection if(with approval of the 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
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property:3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
C Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board or 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 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 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 of more from a private water supply
well". Method use 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:
3
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
D System Failure Criteria applicable to all systems:
You must indicate either"Yes"or"No" to each of the following for all inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is than 1/2 day flow.
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ X Any portion of the SAS,cesspool or privy is below the high groundwater elevation.
_ X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X 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. [The 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 I have determined that one of more of the following failure criteria exist as described in 310 CMR 15.303,
fails. 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 god 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 II of a
public water supply well)
4
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION(Continued)
Property: 3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
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 with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department.
.� Dan@ lugs AmdemdOMMUEY Iles ]DIlMM ,d
i
i
5
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART B
CHECKLIST
Property:3- 17 Louisburg Square/Building 5
Center Village,Hyannis,MA.
Owner: Multiple Owners
Date: Completed 1/19/06
Check if the following have been done You must indicate"yes"or"no"as to each of the following_
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the prevous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum?
_ X 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 on the site has been determined based on:
Yes No
X _ Existing information.For example, Plan at B.O.H.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[I5.302(3)(b)]
6
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION
Property:3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): Number of bedrooms(actual): 16 units.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: Number varies but typically 19 on average.
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): No
Water meter readings,if available(last two(2)year usage(gpd)): Water usage records were not available at time of inspection.
Sump Pump(yes or no): No
Last date of occupancy: 01/19/06—Units were still occupied at time of inspection.
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:Property currently under regular maintenance schedule.
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 2,000 gallons-how was quantity pumped determined?Sight glass on vacuum truck.
Reason for pumping: To determine structural integrity and water tightness of septic tank.
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
No 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)
No Tight Tank. Attach a copy of the DEP Approval
Other(describe)
Approximate age of all components,date installed(if known)and source of information: 36 years per previous inspection.
Were sewage orders detected when arriving at the site(yes or no): No
7
Title 5 Inspection Form 6/15/2000
r
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property:3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
UIlnnt nD&ge 1*1m9eMdGM&1My Ilel DDEMMIk
8
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (61.7)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property: 3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
BUILDING SEWER(locate on site plan)
Depth below grade: 54".
Material of construction: X cast iron 40 PVC other(explain) Cast iron inlet pipe.
Distance from private water supply well or suction line: No known wells in immediate area.
Comments:(on condition of joints,venting,evidence of leakage,etc.)
All piping appeared to be clean and flowing freely.No evidence of leakage.
SEPTIC TANK: YES(locate on site plan)
Depth below grade: 46".
Material of construction: X concrete metal Fiberglass Polyethylene
other(explain)2,000-2al1on precast concrete septic tank.
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes or No):_(Attach a copy of certificate)
Dimensions: 6' deep X 4'wide X 12' long.
Sludge Depth: 3".
Distance from top of sludge to bottom of outlet tee or baffle: 32".
Scum thickness: 4".
Distance from top of scum to top of outlet tee or baffle: 2_'.
Distance from bottom of scum to bottom of outlet tee or baffle: 10".
How dimensions were determined:Measured with a tape.
Comments:(on pumping recommendations,inlet and outlet tees or baffle condition,structural integrity,liquid levels as related to outlet
invert,evidence of leakage,etc.)
Septic tank was pumped at time of inspection.Inlet tee and outlet tees in place as required.Tank is structurally sound and water
tight and all effluent levels were at an appropriate height.There are no repairs recommended at this time.
GREASE TRAP:NQ(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 tees or baffle condition,structural integrity,liquid levels as related to outlet
invert,evidence of leakage,etc.)
9
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property:3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
TIGHT or HOLDING TANK: NO.(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/No)
Date of last pumping:
Comments:(condition of alarm and float switches,etc.)
DISTRIBUTION BOX: YES.(If present,must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 011.
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,
etc.)
Box was structurally sound and water tight and providing even distribution of effluent.Carryover was moderate.There are no
repairs recommended at this time.
PUMP CHAMBER: NOlocate on site lap)(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.)
10
Title 5 Inspection Form 6/15/2000
i
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(61.7)383-1234 (617)545-2800 (61.7)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property:3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
SOIL ABSORPTION SYSTEM(SAS): YES.(locate on site plan,excavation not required)
If SAS not located,explain why:
Type:
X leaching pits,number: 2—6' X 6' leaching pits.
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.):
There was no surface wetness,breakout or signs of hydraulic failure observed.Leaching appears to be in good working condition.
There are no repairs recommended at this time.
CESSPOOLS: NO.(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: NO.(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.)
11
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET]VIA 02025'
(617)383-1234 (617)545-2800 (61.7)749-61.78.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property:3- 17 Louisburg Spuare/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
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.
f
W _
!4P � rearo ,� a
- - C = 30 '
A -D 19. (o
D 34- '
A
B C = 44
i=- 3o "
80-1 -�o Scala &
12
Title 5 Inspection Form 6/15/2000
ROSANO DAVIS
9 ROCKY LANE
COHASSET MA 02025
(617)383-1234 (617)545-2800 (617)749-6178
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART C
SYSTEM INFORMATION(Continued)
Property:3-17 Louisburg Square/Building 5
Center Village,Hyannis,MA
Owner: Multiple Owners
Date: Completed 1/19/06
SITE EXAM
Slope
P
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater: Greater than.19 feet
Please indicate(check)all methods used to determine the high groundwater elevation:
Obtained from system design plans on record. If checked,date of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain:Previous Title 5 Inspection dated 03/29/03.
_ Check local excavators,installers-(attach documentation).
_ Accessed USGS database-explain:
You MUST describe how you established the High Groundwater Elevation:
During a previous inspection on 03/29/03 the high groundwater was indicated to be 19' 7" below grade.Clearly there is separation
from the bottom of the SAS to the high groundwater elevation.It was by this non-intrusive method that it was estimated that
separation exists from the bottom of the SAS and the high groundwater.
13
Title 5 Inspection Form 6/15/2000
:..
C �
4 1996
a
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 °
508-771-9399 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIONn
• �N M i(U t UPa L yG1AA^-t4J
Property Address
Date of Inspection: - - nspect is Name:
Owner's Name and Address: ¢ •?
CERTIFICATION STATEMENT!
I certify that I have personally inspected the sewage disposal system at tlus address and that the informal
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my,training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further Ev uation By Local Aproving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty 00).days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY•
A)SYSTI PASSES:
✓/ I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,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,cracked,structurally unsound,shows substantial infiltration or
Wiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
-1-
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year,due to broken or obstructed pipe(s).
.The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)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 IS FUNCTION-
ING 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
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply 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 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
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
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.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than I/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
-2-
.o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
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 I of a public well.-
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed .
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS;
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 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:
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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and Board of Health.
✓None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
-�As-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow.
✓fhe site was inspected for signs of breakout.
i All system components,excluding the Soil Absorption System,have been located on site.
_Z—The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,,material of construction,dimensions,depth of liquid,
th of sludge,depth of scum.
he size and location of the Soil_Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
� The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RPSIDENTLAi: t/
Design Flow:_ y O sallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder: Laundry Connected To System: yrs Seasonal Use: ,d®
Water Meter Readings,if available:
Last Date of Occupancy:
ATANDIMMALZ-V6
Type of Establishment:
Design Flow: pallons/day Grease Trap Present: (yes or no)
Industrial.Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:.
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informa 'on: G" VV
System Pumped as part of inspection: If yes,volu a pumped: gallons
Reason for.pumping:
TYPE sF SYSTEM:
_LzSeptic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
Other(explain):
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: ,,4,7
-4-
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: [�
Depth below grade:2�_ Material of Construction: ✓concrete metal FRP—Other
(explain)
Dimisions: Sludge Depth: ,3 Scum Thickness: /Z
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert,structural integrity,evidence If leakage,etc.) a 1zX
_e rah ;T
GREASE TRAP:
Depth Below Grade: Material of Construction:_concrete—metal—
FRP—Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING TANK:
—A—/�
Depth Below Grade: Material of Construction:—concrete—metal—FRP—Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: .
Depth of liquid level above outlet invert: .0C'2� �2
Comments: (note if Wei and.distribution i equal,evi nc of solids carryover,evidenc of leakage into
or out of box,etc. . PCs c2 �[
PUMP CHAMBER
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTE
M INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number:_Leaching chambers,number: Leaching galleries,number:
Leaching trenches,,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure level of pending,condition of vegetation,
ek) r A yaZI
G/ , c cr .� �i r
CESSPOOLS:�Q
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(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:./1V
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
Y
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
0
3
DEPTH TO GROUNDWATER: '
Depth to groundwater: 2-/ Feet
Met4od of Determination or ppro unadon: J'—
/O q�1 Gl
-7-
XWPOW
7 0 14, S ,u,0-• Q 711 ®Jam
T O BARNSTABLE 0 Aq
I OCATIO /n // CD SEWAGE #
VILLAGE J`���/� ASSJESSOR'S M P &LqO •��`
INSTALLER'S NAME&PHONE NQl.X>f_) " '
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)' ; ), (size)
NO. OF BEDROOMS
BUILDEK& ki
PERMIT DATE: COMPLIANCE DATE: " 'tea
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�� -
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bl/A\
Y
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