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HomeMy WebLinkAbout0000 FALMOUTH ROAD/RTE 28 - Health Bldg Asterville Pines Falmouth Rd. (Osterville) 0 q q R) - 00 ,I 'f a II I I i Commonwealth of Massachusetts 630— ODA- �� Title 5 Official Inspection Form tI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments x� 3040 Falmouth Road Bldg G Property Address r-� Osterville Pines Condo. f` Owner Owner's Name information is W required for every Marstons Mills MA 02648 11-21-2019 page. Citylrown 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:out When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road ICI Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11-23-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and-copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is Marstons Mills MA 02648 11-21-2019 required for every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom condo has a H-10 1500 gallon septic tank and a d-box feeding a leaching pit with stone at the time of the inspection there were no visible failure criteria found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ale Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑, Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required,pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ . obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No i ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following,in addition to the questions in Section CA. Yes No ❑ ❑ 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 El 0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 . page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. Cityrrown State Zip Code Date of Inspection - D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 44plus GPD Description: Number of current residents: appx. 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: - occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-201.9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) - Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form YI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is Marstons Mills MA 02648 11-21-2019 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.):. water was flushed and it came freely. 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owners Name information is Marstons Mills MA 02648 11-21-2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2011 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-10 1500 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 3411 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 121f How were dimensions determined? Sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached?. ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: one ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is Marstons Mills MA 02648 11-21-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (coat.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 - y Commonwealth of Massachusetts Title 5 Official Inspection Form subs urface Sewage.Disposal System Form-Not for Voluntary Assessments �J 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. er owner's Name MA 0260266448_ 41-21-2019_ - ,nation is Marstons Mills state Zip Code Date of Inspection ired for every Cityrrown D. System Information (cont.) 14. Sketch of Sewage Disposal System: s to at I enters `vide- `a view of the sewage disposal system, including 0 feet1eLocatelwhere publ c water s pp reference Pro landmarks or.benchmarks. Locate all wells within 1 the building. Check one of the boxes below: 0. band-sketch in the area below drawing attached separately , A3 i y e.Dis, sel System Page 16 of 16 r •S , Title 5 o fiaw inspection Form Subsurface$swag pp Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Formi Not for Voluntary Assessments V 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is Marstons Mills MA 02648 11-21-2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: augered a hole to 14 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts TIP 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg G Property Address Osterville Pines Condo. Owner Owner's Name information is Marstons Mills MA 02648 11-21-2019 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 � l qp-63a- Do Q Commonwealth of Massachusetts V w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 ' Osterville Pines -3040 Falmouth Road, Osterville, MA ILDING "E" Property Address Multiple Owners Owner Owner's Name information is ^,f� required for every Osterville, 1_1 MA 02665 04/10/18 1`0 page. City(rown State Zip Code Date of Inspection I 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 /a9�� filling out forms on the computer, use only the tab 1. Inspector: key to move your 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 City/Town State Zip Code 781-383-8888 S149 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 04/19/18 Inspector's Si ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board- of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 04/10/18 page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is Osterville, MA 02655 04/10/18 required for every � page. Cityrrown State Zip Code Date of-inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Osterville Pines -3040 Falmouth Road, Osterville,'MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every- Osterville MA 02655 ' 04/10/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface 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, provlded'that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 04/10/18 required for every- 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- 101 000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large. system considered a significant threat under Section E or failed under 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. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 04/10/18 page. CityrFown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M SV•a Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information.is required for every Osterville, MA 02655 04/10/18 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) 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: Building 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonw ealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 04/10/18 required for every + , page. Cityrrown 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: Condo Association on semi-annual pumping schedule. 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-31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 04/10/18 required for every � page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Previous inspections indicated 34+years. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ` Depth below grade: 36"feet Material of construction: ❑ cast iron ®40 PVC other(explain): Schedule 40 PVC 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: 2'w/cast iron covers to grade on inlet and outlet. Material of construction:_ ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 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: 5'wide X 5'deep X 8' long. 6„ Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts WOW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 04/10/18 required for every_ � page. Cityrrown 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 30" 6.. Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" i 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.): Tank was structurally sound and watertight and all effluent levels were at an appropriate height. Inlet and outlet tees are in place.There are no other 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•3113 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 Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 04/10/18 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: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 04/10/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0,l 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): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 04/10118 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number* ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness or breakout observed.There were no signs of hydraulic failure observed. SAS appeared to be in proper working condition. Cover is 2" below grade.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 Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M ,••'y Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, - MA 02655 04/10/18 page. Citylrown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,• Osterville Pines -3040 Falmouth Road;Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 04110/1.8 page. Cityrrown 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 d i 6 O A I 3 3' a I 9114, 7714 a ;6164 0 3 of t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 04/10/18 page. Cityrrown 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 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 18.3' below grade.This determination was by Frimptor method. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the seasonally high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02656. 04/10/18 required for every � page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist 0 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 do _I .� "` ` ►, it .' �-� � $ 3 t hReurJ+�- WA':41 w I1�.aw-.wrr.I.__r�_+r_+��. _���...n ._.._.-ram—. ._...-... .r_._..r. �,r��_.n-.__.�._—.� ..• —_ .^+� Bid t5ins•3/13 Title 5 Official Inspection Forth:Subsurface •Sewage Disposal System Page 17 of 17 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 09/18/14 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your 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 City/Town State Zip Code 781-383-8888 SI49 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 09/25/14 Inspector's Sig ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Su surface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owners Name information is Osterville MA 02655 09/18/14 required for every � page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 09/18/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 09/18/14 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 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Citylrown 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Water meter readings were not available at time of inspection. Sump pump? ❑ Yes ® No Last date of occupancy: Buildingoccupied. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available:. t5ins-3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 7 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown 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: Condo Association on semi-annual pumping schedule. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,000 gallonsgallons How was quantity pumped determined? Sight glass on pump truck. Reason for pumping: To determine structural integrity and watertightness of septic tank. i Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Previous inspections indicated 30+years. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ® 40 PVC other(explain): Schedule 40 PVC inlet pipe. ® Distance from private water supply well or suction line: No known wells in immediate area. i 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: 2'w/cast iron covers to grade on inlet and outlet. Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast concrete septic tank. If tank is metal, list age: years Is age confirmed b a Certificate of Compliance? attach a co of certificate Yes No 9 Y P ( PY ) ❑ ❑ Dimensions: 5'wide X 5'deep X 8' long. Sludge depth: 5" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown 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 31" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 15" I 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.): Septic tank was pumped at time of inspection.Tank was structurally sound and watertight and all effluent levels were at an appropriate height. Inlet and outlet tees are in place.There are no other 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02665 09/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L i — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02665 09/18/14 required for every � 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02656 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness or breakout observed.There were no signs of hydraulic failure observed. Leach pit is 72"deep and had 12"of water in it. SAS appeared to be in proper working condition. Cover is 2" below grade.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 Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 09/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown 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 c f I � 0 cfl) A 3 3' a 371411 i 0 3 60, 3 Liss i �y t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °,M z Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. CitylTown 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 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 18.3' below grade.This determination was by Frimptor method. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the seasonally high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 09/18/14 page. Cityrrown 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 Iq WA�i2 _ Bid E t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 yq lP 1 I Commonwealth of Massachusetts, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - g ,M °t Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/02/11 required for every - page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see.completeness checklist at the end of the form. Important:When filling out forms A. General Information t . on the computer, use only the tab 1. Inspector: key to move your 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 City(rown State Zip Code 781-383-8888 S149 Telephone Number License Number . B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally.Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 03/03/11 Inspector'slAgnature 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 r< 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. Title 5 Official Inspection Form:Subsurface Sewage Dis sal S stem•P3 e 1 of 17 t5ins•osioa Rosano Davis Sanitary Pumping,Inc 787-383-8888 ' a s v s 1 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Citylrown 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): t t5ins•ogrot Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 GSM , Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING'"E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Citylrown 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): • i ❑ 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•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface 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 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: t a N D) System Failure Criteria°Applicable to All Systems:' . You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ` ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS o•r 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 '/2 day flow t5ins•ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 F M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) P , 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) 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, perforined 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 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 16,000 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 Fj ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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•og=Rosano Davis Sanitary Pumping,Inc ,781-383-8888 Title 5 official Inspection Form: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 °M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 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 ❑ 0 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. y ` ® ❑ - 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310,CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd. s t5ins•.ogioe Rosano Davis Sanitary Pumping,Inc '781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -{ Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/02/11 required for every - _ page. Cityrrown State Zip Code a Date of Inspection D. System Information Description: Unknown. Number of current residents: Does residence have a garbage,grinder? ❑ Yes ® No - u Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? , ❑ 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: 03/02/11 - Building 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.): S , Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? 4 ❑ Yes '❑ -No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No f Water meter readings, if available:" t5ins•ogios Rosano Davis Sanitary Pumping;Inc '781-383-8888 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 M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): , General Information Pumping,Records: Condo Association on yearly maintenance Source of information: schedule. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1 gaallollo gallons ns How was quantity pumped determined? Sight glass on pump truck. Reason for pumping: Yearly maintenance&to determine structural integrity &watertightness of septic tank. Type of System: ® Septic tank, distribution box„ soil absorption system ❑ Single cesspool ❑T 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.1/A system by system operator under contract ❑ Tight tank..Attach a copy of the DEP approval. ❑ Other(describe): t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) Approximate age of all components, date installed (if known)and source of information: 27+ years per previous inspection. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36•'w feet Material of construction: ❑ cast iron - ® 40 PVC ❑'other(explain): Schedule 40 PVC inlet pipe. Distance from private water supply well or suction line: No known wells in area. feet 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(locate on site plan): 2'w/cast iron covers to grade on ' Depth below grade: inlet&outlet. Material of construction: A ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast concrete septic tank. y Y If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑. No Dimensions: 5'wide X 5'deep X 8' long. Sludge depth: 6-1 t5ins•o9io8 Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners _ r Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown 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 30" Scum thickness Distance from top of scum to top of outlet tee'or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" - 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.): . Septic tank was pumped at time of inspection. Tank was structurally sound and watertight and all effluent levels were at an appropriate height. Inlet and outlet tees in place.'There are no repairs recommended at this time. r 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-ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address ' Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. CityrFown State Zip Code Date of inspection D. System Information (coot.) . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time,of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: • gallons Design'Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No II t5ins-ogios Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11`of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "El' Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown State f Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 01, 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.): Box was structurally sound and watertight and providing even distribution'of effluent._ Carryover was moderate. There are no repairs recommended at this time w - t Pump Chamber}(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: El 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•og/oa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address r Multiple Owners Owner Owner's Name information is Osterville MA 02655' 03/02/11. required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: _ ® leachinn g pit. leaching pits number. " 1 X . . . ❑ 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 pit is 72" deep and had 16"of water in it.There was 50" of available capacity. Cover is 2" below grade. Leaching appears to be in proper working condition. 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 ' Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1. 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y' Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name "+ information is Osterville MA 02655 03/02/11 required for every J - page. Cityrrown 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.): - 1 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.): . y F s f i t5ins-09108 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts__, s . Form - Tale, 5 Official Inspection Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"E" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/02/11 required for every page. Cityrrown 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 r - A4 EF >4 Al ` 3 3.r 3 3 601 @'4* d t5ins•psio8 Rosano Davis Sanitary Pumping,Inca 781-383-8888. + Title;5 Official Inspection Form:Subsurface Sewage Disposal System-,Page 15.of 17; J , , Commonwealth of Massachusetts ' IMF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "E" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. City/Town 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 inspections. ❑ Checked with local excavators, installers-(attach,documentation) ❑ Accessed USGS database-explain: You.must describe how you established the high ground water elevation: During a previous inspection the high groundwater was indicated to be 18'3" below grade. This determination was by'Fripter method. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the high groundwater. a I . Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•osioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"E" ; Property Address Multiple Owners « Owner Owner's Name , information is required for every Osterville MA - 02655 03/02/11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information-Estimated depth to high groundwater E Sketch of Sewage DisposaltSystem either drawn on page 15 or attached in separate file 3 �A,I.H hCLeu��� - I1�•aw.M....I.--r•_�.r�• w+w_-. �..-' - r+ rr. ..-.�n ...� •-..��• �. ��.•rw_.1�._-�•. _-!1� t5ins ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System_•Page 17 of 17 Town of Barnstable d� F THE r Regulatory Services Barnstable O o Thomas F. Geiler,Director ;mericaCity Public Health Division BARNSTABLE, 9 MASS. Thomas McKean,Director 200� �Ar 1639. s`0 200 Main Street FO NAA't Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 November 3, 2009 John D. & Penny A. Scott P.O. Box 786 West Barnstable, MA. 02668 RE: Assessors (map-parcel) 099-030 As of October 1, 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at`(304W170mouth Road;i7nit CE_1_;_Marstons.MiH1s;_MA Q2648_ 7-3 Enclosed is an application. Please use a separate application for each rental unit you own. Should you need more applications, they are available online at www.town.barnstable.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2009 fees included. Please contact me to schedule inspection of the property as soon as possible. If there are tenants presently occupying the property please provide the contact information being sure to include a daytime phone number for all tenants. For your use an occupant's permission form has been included to allow for inspections to be performed in the tenant's absence. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call '508-862-4072. Thank you in advance for your cooperation. Teresa Wright Division Assistant Health Division Direct#508-862-4072 Health Master Detail Page 1 of 1 Logged In As: TOWN\wrightt Health Master Detail Tuesday, Novem Application Center Parcel Lookup Parcel Septic Perc Well Fuel Tank Parcel: 099-030-OOQ Location: 3040 FALMOUTH ROAD/RTE 28, MARSTONS MILLS Owner: SCOTT, JOHN D Business name:' i Business phone: Rental property: (-- Deed restricted: ❑ Number of bedrooms Contaminant released: FFuel storage tank permit: Save Parcel Changes _I Return to Lookup Parcel Info Parcel ID: 099-030-OOQ Condo unit: UNIT E1 Condo complex:OSTERVILLE PINES Building: Location:3040 FALMOUTH ROAD/RTE 28 Primary frontage: Secondary road: Secondary frontage: Village: MARSTONS MILLS z Fire district:C-O-MM Sewer acct: Road index:0522 Interactive map M - _ Town zone of contribution:GP (Groundwater Protection Overlay District) State zone of contribution: IN Owner Info Owner: SCOTT, JOHN D & PENNY A Co-Owner: Streetl: PO BOX 786 Street2: City:W BARNSTABLE State: MA Zip: 02668 G Deed date:9/15/1986 Deed reference: 5328/129 Land Info Acres: 0 Use: Condominiu MDL-05 Zoning: RF Neighborhood: 0 Topography: Road: Utilities: Location: Construction Info Building NoYear Built Effective Area Bedrooms Bathrooms 1 1966 513 12 Bedroomsl Full Buildings value:$157,800.00 Extra features: $0.00 Land value: $0.00 a 1 1 1 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=09903000Q 11/3/2009 SECTION:SENDER: COMPLETE THIS . . ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent Is Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. celved by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, -r T' or on the front If space permits. D. Is del' d n m item 1? ❑Yes 1. Article Addressed to: If Y= enter I' re below: ❑No � h John D. & Penny A. Scott P.O. Box 786 3. ServlceTyp West Barnstable, MA. 02668 *Certified Mail ❑Express Mail Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service labe�j{ ; t 'I I'( 7,0 0;5 1116 0 C0 19 + 9 4i 6`.1 PS Form 3811 February 2004 Domestic Return Receipt 102595-024-1540 UNITED STATE �AL' Ear :$A � •. 11 T : +�e - t j • Sender: Please print your name, address,and ZIP+4 W5this �x • I w ao ToW6'of Bar nsta.. e -� r Public Health Division � 200 M,ain'Street- �ayGr.nis, MA. 02601 �I IR III!!L'ItIIiI'll III Mil 11l11liil 1AI IIdfilj I I D^ Er 0 ErOFFICIAL -U-S-E r� Postage $ � O Cl Certified Fee a �ov �® .y l7 Return Receipt Fee e (Endorsement Required) l:3 Restricted Delivery Fee 0 (Endorsement Required) �s ,� pS Total Postage&Fees u7 Sent To �` Street Apt No:;- ............I or PO Box No. 4- 6 p, 7 U 6 City Stets.ZIP+4 Certified Mail Provides:a A mailing receipt (ea,eneli)zooz eunrooee 111,0=1 sd e A unique identifier for your mailpiece e A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. e Certified Mail is notavailable for any class of international mail. ® NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ® For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ® For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry: Internet access to delivery information is not available on mail addressed to APOs and FPOs. COMMONWEALTH OF MASSACHUSETTS ID y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ti d DEPARTMENT OF ENVIRONMENT TION A RECEIVE ' 5V JUN 2 9 2001 TO�NH BLE EA DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:Building E,Osterville Pines,Falmouth Rd.Osterville,Ma Owner's Name:Huntingest Management(Osterville Pines Condo Trust) Owner's Address:Unit#c,40 Industry Road,Marston Mills,MA 02648 Date of Inspection:06-12-01 Name of Inspector:Brian T.Axon , Company Name:A&K Septic Systems Plus Mailing Address:565 Carriage Shop Road East Falmouth,MA 02536 Telephone Number:508-540-6706 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature�a _\ Date: 06-12-01 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System functioning fine.There are no violations of failure criteria.System consists of 1500 gallon tank,D-box and leaching 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Bldg E,Osterville Pines,Falmouth Rd,Osterville,MA Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection:06-12-01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 es no or not determined N ND in the for y (Y, ) o 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:Bldg E,Osterville Pines,Falmouth Rd.,Osterville,MA Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection:06-12-01 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: I , 4 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:Bldg E Osterville Pines,Falmouth Rd.,Osterville,Ma Owner:Huntingest Management(Ostervile Pines Condo Trust) Date of Inspection:06/12/01 D. System Failure Criteria applicable to all systems: You must indicate"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 less than%Z 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 high ground water elevation. x Any portion of 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. [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.] (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 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. i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:Bldg E,Osterville Pines,Falmouth Rd,Osterville,MA Owner:Huntingest Management Date of Inspection:06112101 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 previous two week period? X 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)_ 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 all system components,excluding the SAS,located on site? X _ 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? 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(SAS)on the site has been determined based.on: Yes no X _ 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:Bldg E Osterville Pines,Falmouth Rd,Osterville,MA Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection:06-12-01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual):4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440 Number of current residents:5 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 2 years usage(gpd)):NA Sump pump(yes or no):no Last date of occupancy: current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): gpd Basis of design flow(seats/persons/sqft,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:Last pumped Dec 2000/project manager 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 X 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:20+years Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Bldg E,Osterville Pines,Falmouth Rd. ,0sterville,MA Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection: 06/12/01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan). Depth below grade: 2' Material of construction: x 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: 10'6"x 57' Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 34" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined:Field instruments Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend pumping every two years.Tees liquid level in relation to tees and structural integrity are all fine.No evidence of leakage. GREASE TRAP: NA(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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Big E,Osterville Pines,Falmouth Rd,Osterville VIA Owner.Huntingest Management(Osterville Pines Condo Trust) Date of Inspection:06/12/01 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: x (if present must be opened)(locate on site plan)_ Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,,any evidence of leakage into or out of box,etc.): Distribution equal.No evidence of solids carry over.No evidence of leakage. PUMP CHAMBER:NA(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.): f Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Big E,Osterville Pines,Falmouth Rd. Osterville,MA Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection: 06/12/01 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: I 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.): Condition of soils and vegetation fine.No evidence of hydraulic failure.. 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:Bldg E,Osterville Pines,Falmouth Rd,Osterville,MA Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection: 06/12/01 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. i A B AC 3 3' 6C agTf 0 AID 3T6„ O f - AF �v 6 z, page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Bldg E.Osterville Pines,Falmouth Rd,Osterville,MA . . Owner:Huntingest Management(Osterville Pines Condo Trust) Date of Inspection:06/12/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 14+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: x Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: x Checked with local.excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: New leaching installed at Bldg.D.No groundwater at 14'.