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HomeMy WebLinkAbout3040 FALMOUTH ROAD/RTE 28 - Health (2) r 3040 Falmouth Rd. , Osterville A= 099-030-00x /A ogc7--O3U--COL, oS I S v 4 O n . Commonwealth of Massachusetts o 9qd o� a- 00Y Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form:- Not for Voluntary Assessments c,V Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is Osterville ✓ MA 02655 06/01/2020 required for every page. City/Town State Zip Code Date of Inspection 3 ;' 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. Inspector Information S1 filling out forms 4y► on the computer, use only the tab Paul W. Davis key to move your Name of Inspector cursor-do not Rosano Davis Sanitary Pumping, Inc. use the return Company Name key. 9 Rocky Lane 116 Company Address Cohasset MA 02025 City/Town State Zip Code 781-383-8888 SI 49 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. 0 Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 05/04/2020 Inspector's gnature 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 �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 05/01/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / a , Osterville Pines -3040 Falmouth Road Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 05/01/2020 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 rn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road,.Osterville, NIA BUILDING "G Property Address Multiple Owners Owner Owner's Name information is �required for every Osterville MA 02655 05/01/2020 page. CityTrown 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 ❑ M 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 M1 - p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 05/01/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 ❑ ® 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. ❑ 0 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 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 ❑ M the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I I of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M e Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" —u- Property Address Multiple Owners Owner Owner's Name information is �required for every Osterville MA 02655 05/01/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑. ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? E ❑ 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) [31.0 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �rM Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"G" �Z�JVtl, Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 05/01/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Varies 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 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: Current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"G" V Property Address Multiple Owners Owner Owner's Name information is required for every Osterville,. MA 02665 05/01/2020 page. City/Town 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 Y(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: Condominium Association on semi-annual pumping schedule. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,500 gallons gallons How was quantity pumped determined? Sight glass on pump truck. Reason for pumping: To determine structural integrity and watertightness of septic tank. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02656 05/01/2020 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): Septic tank,soil absorption system. Approximate age of all components, date installed (if known) and source of information: 36+/-years per previous inspection. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28..feet Material of construction: ❑ cast iron ® 40 PVC Schedule 40 PVC inlet pipe. . ❑other(explain): Distance from private water supply well or suction line: No known wells in immediate are. feet Comments (on condition of joints,venting, evidence of leakage, etc.): Inlet pipe appeared to be clean and flowing freely. No evidence of leakage. t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts �m Title 5 Official Inspection Form �P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is +required for every Osterville MA 02655 06/01/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 20"w/covers to grade on inlet and outlet. Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1,500-gallon precast concrete septic tank. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'wide x 5'deep x 10' long 5„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 31. Distance from top of scum to top of outlet tee or baffle W. 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. Recommend installing Zabel effluent filter in outlet tee to prevent solids from entering SAS. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V Osterville Pines -3040 Falmouth Road; Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owners Name information is required for every Osterville, MA 02655 05/01/2020 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i ` Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING °'G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02656 05/01/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) .8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 05/01/2020 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: 1 -concrete leaching pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 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 "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 05/0112020 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness or breakout observed.There were no signs of hydraulic failure observed. SAS appeared to be in proper working order.There are no repairs recommended at this time. 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 pi 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 05/01/2020 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is ill terve, required for every Os MA 02656 06/01/2020 page. Cityrrown State. Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 13y i idil�g A - Z � � T 4C Of 40 It - ex pose . C0Vt y1 i (ks wail c(s mid6le coue.lr. � 5 C 1C, t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 16 of 18 Commonwealth of Massachusetts IR Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � ! Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 05/01/2020 page. Cityfrown 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 round water: SEE BELOW p g g 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 on 11/07/03 the high groundwater was indicated to be 18.25' 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. . Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "G" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 05/01/2020 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 New leaching installed at Bldg.D.No groundwater at ljr. 6? I 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I �9q-bab-�o� Commonwealth of Massachusetts ,i� Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c- d_ 3040 Falmouth Road Bldg C Property Address h Osterville Pines Condo. fi Owner Owner's Name information is Y required for every Marstons Mills MA 02648 11-21-2019 -, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:out forms A. Inspector Information filling out forms 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 City/Town 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 I Commonwealth of Massachusetts Title 5 Official Inspection Fora 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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 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 4 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments emu- 3040 Falmouth Road Bldg C 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.) " 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/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 Area 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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.) 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? ® El 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? ® El Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? .The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i 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 C 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 1. 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 plus GPD Description: Number of current residents: appx. 5 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 Seasonaluse? ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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.) 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 ,p Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . V 3040 Falmouth Road Bldg C 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.) 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): 3011 Depth below grade: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sew age Disposal System Form Not for Voluntary Assessments 3040 Falmouth Road Bldg C Property Address Osterville Pines Condo. Owner Owner's Name information is required for every Marstons Mills MA 02648 11-21-2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 20"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 to of sludge to bottom of outlet tee or baffle P 9 34' 1„ Scum thickness Distance from top P of scum to to of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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 �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments . .�!% 3040 Falmouth Road Bldg C 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts lip Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert oil 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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 Fora I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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.) 11. Soil Absorption System (SAS) (cont:) 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 h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 3040 Falmouth Road Bldg C 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.) 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 I Commonwealth of-Massachusetts- i Titlel5-,0,ff Ci.al_.lns- pection form Subsurface Sewage..Disposal System Form-Not for Voluntary Assessments 3040 Falmouth Road Bldg C Property Address Osterville Pines Condo. vner Owner's Name piredfor every ifo is Marstons Mills MA 02648 11-21-2019 auired ge, Cityg wn .; -s State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate allwells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: -hand-sketch in the area below 0 drawing attached separately a.tY ' a. '; 1.',T.. ..'" - `w f.�k •.iKi1t'wti , , LT 1 'Lank' 0 0 a 3 � A 1 35,in a 3`' 3 4,24 a 1 9151 3 Soy`" iinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 14 plus feet Estimated depth to high ground water: 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: I 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 1 Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3040 Falmouth Road Bldg C 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 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 Miorandi, 'Donna From: MacNeely, Martin <mmacneely@commfiredistrict.com> P Sent: Wednesday, June 27, 2018 8:27 AM To: Miorandi, Donna Subject: Osterville Pines Donna, ' Property manager information: Tina Dionne 508-420-7472 imscapecod@msr:corn Martin N, p c� Grt 1l,P D�6 p�� Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -Building C (Concord) Property Address `:•;� Multiple Owners •: Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville, MA 02655 09/30/16 I-+ page. City/Town State Zip Code Date of Inspection W i0 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 f/9a5 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 Citylrown 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. 1 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 10/05/16 Inspector's SiVature 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �a Vs • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Osterville> MA 02656 09/30/16 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: ® 1 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 Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -Building C (Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 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): ' r ❑ 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•3113 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 -Building C (Concord) Property Address Multiple Owners Owner Owner's Name information is >required for every 3040 Falmouth Road Osterv > ille MA 02655 09/30/16 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 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02665 09/30/16 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -Building C(Concord) ' Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Ostery > ille MA 02655 09/30/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ .Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins-3/13 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 M Osterville Pines-Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Osterville MA 02655 09/30/16 page. Cityrrown 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 g y ry y p 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: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M Osterville Pines-Building C (Concord) Property Address Multiple Owners Owner Owners Name information is required for every 3040 Falmouth Road, �Osterville MA 02655 09130/16 -- 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 maintenance 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): Septic tank,soil absorption system. t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville, MA, 02666 09/30/16 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: 32+years per previous inspections. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): All piping appeared to be clean and flowing freely. No evidence of leakage. Septic Tank(locate on site plan): Depth below grade: 15"w/covers to grade. feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,500-gallon precast concrete septic tank. If tank is metal, list age:. years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'wide X 5'deep X 10' long. Sludge depth: t5ins•3113 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 Osterville Pines -Building C (Concord) Property Address Multiple Owners - Owner Owners Name information is required for every 3040 Falmouth Road, >Osterville MA 02656 09/30/16 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" 211 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 18" 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 is on a semi-annual maintenance pumping schedule and was not 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. 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 I Commonwealth of Massachusetts Title 5 Official Inspection on Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every > > 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: Dat e Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines-Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville MA 02655 09/30116 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 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.): Pump (locate on sit Chamber I n ePa ): . Pumps in working order: ❑ Yes ❑ Nci* Alarms in working order: µ ❑ 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 f Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M °r Osterville Pines-Building C (Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Ostery > ille MA 02655 09/30/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -concrete leaching pit. ❑ leaching chambers number: ❑ leaching galleries' number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness, breakout or signs of hydraulic failure observed. Leaching pit dry at time of inspection. 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 15ins-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 -Building C (Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09130/16 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.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments M . Osterville Pines-Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Osterville, MA 02655 09/30/16 page. City/Town 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 f�Ui�C�ll� C P1 A _ = 4-5 f r SC�c�-c c�l s�l�fic 30t �- 3 - 41,5 ` A-1 i covers t� grucPe. O j\l A.�o sco.l e, 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 Osterville Pines -Building C(Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, �Osterville MA 02665 09/30/16 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: ❑ 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 on 11/07/03 the high groundwater was indicated to be 18.25' 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. 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 M Osterville Pines -Building C (Concord) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Ostery > ille MA 02665 09/30/16 page. City/Town 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 New leaching installed at Bldg.D.No groundwater at 14'. 5 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ca M Osterville Pines -Building D(Dover) Property Address ` Multiple Owners . Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville, MA 02656 09/30116 page. City/Town State Zip Code Date of Inspection W 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 A. General Information fillip 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. to r� Company Name 9 Rocky Lane Company Address Cohasset MA 02025 Cityrrown 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. 1 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 10/06/16 Inspector's Si66ature 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville, MA 02655 09/30/16 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: ® l 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY �M Osterville Pines-Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 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 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is.required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 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 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M Osterville Pines-Building D (Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, �Osterville MA 02655 09/30/16 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. ❑ Z 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-Building D (Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Ostery > ille MA 02655 09/30/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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 ow, ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines-Building D (Dover) Property Address Multiple Owners Owner Owners Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 page. Cityrrown 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 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: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M Osterville Pines--Building D (Dover) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 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 maintenance 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): Septic tank,soil absorption.system. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Osterville, MA 02655 09/30/16 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: 32+ years per previous inspections. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"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.): All piping appeared to be clean and flowing freely. No evidence of leakage. Septic Tank(locate on site plan): Depth below grade: 20"w/covers to grade. feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1,500-gallon precast concrete septic tank. If tank is metal, list age: years . Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'wide X 5'deep X 10' long. Sludge depth: 5" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, �Osterville MA 02655 09/30/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness V. 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 is on a.semi-annual maintenance pumping schedule and was not 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. 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 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is �required for every 3040 Falmouth Road, Osterville MA 02655 09130116 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Ostery > ille MA 02655 09130/16 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 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.): 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 -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Ostery > ille MA 02655 09130/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -concrete leaching pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:, ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness, breakout or signs of hydraulic failure observed. Leaching pit had 24"of water in it. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 ssachusetts Commonwealth of Ma Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville MA 02655 09/30/16 page. City/Town State Zip Code Date of Inspection . D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Ostery � ille MA 02655 09/30/16 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 I U 01n 15 _ 3 , 1 A - � = �� � :-It i enpc�s�c�cover t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M Osterville Pines -Building D(Dover) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Ostery > ille MA 02655 09/30/16 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: ❑ 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 on 11/07/03 the high groundwater was indicated to be 18.25' 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. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 -Building-D (Dover) Property Address Multiple Owners Owner Owner's Name information is required for every > 3040 Falmouth Road Osterville MA 02655 09/30/16 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 New iraching installed in 1/2600.No groundwater at 14'. i I i tt • �; f,2 3 W61A lLa,,3 PDZUs•�"' / t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 u- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a wM Osterville Pines-Building F(Franklin) Property Address '-j Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville, MA 02655 09/30/16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms I# Il D 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 ICI Company Name 9 Rocky Lane - Company Address ,ena„ 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 ( I�❑ Needs Further Evaluation by the Local Approving Authority 10/05/16 InspectoPs ature Date y 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 �d VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5.1Osterville Pines Building F (Franklin) - Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road,Osterville, MA 02666 09/30116 required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Ostery > ille MA 02655 09/30/16 page. Citylrown 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-3113 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 -Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Ostery � ille MA 02655 09/30/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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 ❑ z ,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 '/2 day flow t5ins•3113 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-Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Osterville MA 02655 09/30/16 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 II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat,. or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M Osterville Pines -Building F (Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, �Osterville MA 02655 09/30/16 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM Osterville Pines-Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville, MA 02655 09/30/16 page. Cityrrown 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: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 . 09/30/16 page. Citylrown 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 maintenance schedule. Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons • y i 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-3/13 Title 5 Dffidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines-Building F (Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 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: System upgraded in 1996 per previous inspections. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: El cast iron ®40 PVC Cast iron inlet pipe. ❑ other(explain): Distance from private water supply well or suction line: No known wells in immediate area. Comments(on condition of joints, venting, evidence of leakage, etc.): All piping appeared to be clean and flowing freely. No evidence of leakage. Septic Tank(locate on site plan): •Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) se 1,500- allon recast concrete tic tank. 9 P p 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 6'deep X 10.5' long. Sludge depth: 4'1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Osterville, MA 02655 . 09/30/16 page. Citylfown 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 32" V. Scum thickness 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 13 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 is on a semi-annual maintenance pumping schedule and was not 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. 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 �M Osterville Pines-Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 page. CityrFown 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 " . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M Osterville Pines -Building F (Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville MA 02655 09/30/16 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 oil 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 wM Osterville Pines -Building F (Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -concreteleaching pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system L 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 had 46"of water in it. 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-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 -Building F (Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, >Osterville MA 02655 09/30/16 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.): 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 ,M Osterville Pines -Building F (Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road,Osterville MA 02655 09/30/16 page. CityrTown 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 rear a - D - �3e C y f L _ 4 m box lPaChlTly P T i I1laf f o scczLr� t5ins•31.13 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 Osterville Pines-Building F(Franklin) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road, Ostery � ille MA 02665 09/30/16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water:, SEE BELOW feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: " Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) d ® Checked with local Board of Health-explain: Previous inspection dated 08/02/99. ❑ 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 on 08/02/99 the high groundwater was indicated to be approx.21' below grade.This determination was approximated and based on information from the Dept. of Interior Geological Survey and USGS database. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM Osterville Pines-Building F(Franklin) Property Address Multiple Owners Owner Owners Name information is required for every 3040 Falmouth Road, Ostery > ille MA 02655 09/30/16 page. Citylrown 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 ll f t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ,,af 9080 Commonwealth of MassachusettsG Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c M Osterville Pines-Building G Groton Property Address Multiple Owners w: Owner Owner's Name information is 3040 Falmouth Road Osterville, MA 02655 09/30/16 required for every � page. City/Town State Zip Code Date of Inspection t�D 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 Cltyfrown 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 D.EP 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 10/05/16 Inspector's Situ 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•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Y V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines-Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is �required for every 3040 Falmouth Road Osterville, MA 02655 09/30/16 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 F ❑ 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 -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is �required for every 3040 Falmouth Road Osterville MA 02655 09/30/16 page. Citylrown 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 (cunt.): ❑ 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: El 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02665 09/30/16 required for every > 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 El ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ z 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 f Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M Osterville Pines -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every > _ page. CitylTown 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 j 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 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-Building G(Groton) Property Address Multiple Owners Owner Owner's Name information is +required for every 3040 Falmouth Road Osterville, MA 02655 09/30/16 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? Z ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -Building G(Groton) Property Address Multiple Owners Owner Owner's Name information is required for every 3040 Falmouth Road Osterville MA 02655 09/30/16 page. Cityrrown 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: Current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines-Building G(Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every > > page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Condo Association on maintenance 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): Septic tank,soil absorption system. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 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: 32+years per previous inspection. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"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.): All piping appeared to be clean and flowing freely. No evidence of leakage. Septic Tank(locate on site plan): Depth below grade: 20"w/covers to grade. feet Material of construction: ® concrete ❑ metal '❑ fiberglass ❑ polyethylene ❑ other(explain) 1,500-gallon precast concrete septic tank. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'wide X 5'deep X 10'long. 511 Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building G(Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every � � page. Cityfrown 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 27" Scum thickness 1;' 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 16" 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 is on a semi-annual maintenance pumping schedule and was not 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. 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-Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is >required for every 3040 Falmouth Road Osterville> MA 02665 09/30/16 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 I Design Flow: gallons per day Alarm present: El-'Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is +required for every 3040 Falmouth Road Osterville, MA 02655 09/30/16 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 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.): 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 Osterville Pines -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every > > page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - Type: ® leaching pits number: 1 -concreteleaching pit.. ❑ leaching chambers number: ❑ leaching galleries' number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness, breakout or signs of hydraulic failure observed. Leaching pit had 22"of water in it. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments Osterville Pines -Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every >' � page. CityrTown 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, 4 etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is �required for every 3040 Falmouth Road Osterville MA 02655 09/30116 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 8f_J�.ic��fl7 C-7 A 4U 15CO- ,� ' sepfic ° i ex�posecLcc�ve_�� = 40 � a s we-! I as M I'd cl 1 e Coves IVOn 7LO caL(2, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines-Building G (Groton) Property Address Multiple Owners Owner Owner's Name information is > >required for every 3040 Falmouth Road Osterville MA 02655 09/30/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: El 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: During a previous inspection on 11/07/03 the-high groundwater was indicated to be 18.25' 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. 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-Building G(Groton) Property Address Multiple Owners Owner Owner's Name information is 3040 Falmouth Road Osterville MA 02655 09/30/16 required for every > > page. CityTrown 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 New leaching installed at Bldg.D.No groundwater at ljl'. i G ;'6-'z' - NcH IhR�V.J7 ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 oFtHE ra,, Town of Barnstable Regulatory Services i r r f * BARNSTABLE. MASS. $i639. Public Health Division �0 ArFD"A°� Thomas McKean,Director 200 Main Street, Hyannis, MA 02601. Office: 508-862-4644 Fax: 508-790-6304 March,14,2014 Sriruen Chunephisal 3040 Falmouth Rd. Unit D1 Osterville, MA. 02655 EMERGENCY CONDEMNATION AND ORDER TO VACATE Finding of Unfitness for Human Habitation and Determination of Immediate Danger In accordance with M.G.L. c.1-11, sec. 127A and 127B, 105 CMR 400.000: State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter II: Minimum Standards of Fitness for Human Habitation, Jim Parziale RS, Health Inspector for the Town of Barnstable, on March 13, 2014, conducted an inspection of the dwelling located at 3040 Falmouth Rd. Unit D-1 Osterville, Massachusetts. The owner's name in this dwelling is Sriruen Chunephisal. Based on the results of that inspection, the Barnstable Health Department finds that the dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and 105 CMR 410.831 (D), the Health Department further finds that the conditions within the dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay may be permitted in making this finding. Conditions found within the dwelling, which give rise to the emergency finding of unfitness and determination of immediate danger, include: 410. 450: Means of Egress 410. 451: Egress Obstruction 410. 452: Safe Conditions 410. 750(G): Conditions Deemed to Endanger or Impair Health or Safety Large piles of personal belongings were observed stacked up in the apartment completely blocking egress and passageways. Front and only door to dwelling could only be opened roughly one foot and led only to a wall of stacked up belongings. t Based upon these findings any and all occupants are hereby ordered to vacate and the landlord/owner is ordered to secure the subject dwelling within 48 hours of receipt of this order. If any person refuses to leave a dwelling or portion thereof, which was ordered vacated she may be forcibly removed by the local Board of Health (Massachusetts General Laws C. 12713), or by local police authorities at request of the Board of Health. Furthermore, anyone who fails to comply with any order of the board of health may be subject to fines ranging from $10-$500. Each day's failure to comply with an order shall constitute a separate violation. Once vacated this unit may not be occupied without the written approval of the Board of Health. Note: This is an important legal document. it may affect your rights. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, CHO\RS Director of Public Health Town of Barnstable Town of Barnstable Public Health DivisionRUMn o�p �sry�� "B`�a 200 Main Street Eon+° Hyannis, MA 02601 � _ / WTNEY BOWES 02 1 A $ 00.390 0004606238 FEB 05 2007 MAILED FROM ZIP CODE 02601 i NIXIE 01-09 i 00 02/10/07 RETURN 'TO SENDER NO MAIL. RECEPTACLE UNABLE TO FORWARD 9 OC:11 028t01400.200)) *0969-09 3 69-05-09 0260104002 I��DIIJII)�I�1DI��U1111�11�11���)I11'll)11�f'��I11�111J4'1�1f .. _� ...:--..�.r���1-,.,�� �ti._- •�•—"--`�._.�-` ��.._'�_�-.--•:-..-ti - `wa::..,:..r...-yea-:_�L. "��*.�'.,,,, t, J -�. _t /-„"�+,�� �. \ v� _ •:: •: •; •• i ji is i � �ie iii is e; 'i •• i i iti t i i t t tt �t it, tit Hi it it it Certified Mail#7006 0810 0000 3524 8240 pFz rp�. Town of Barnstable j Regulatory Services � IIARNS'TAIILE„ 9 MAS8 N Thomas F. Geiler, Director �p 16gq. ArEaµA�°' Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 February 5, 2007 Herb Pugatch 211 Parker Street Newton, MA 02549 NOTICE TO ABATE:VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property'"owned by`you'located a'f3040 Falmouth Road-Apt'-F1;Mafstoris Mills.:-was' inspected on January 23, 2007 by Timothy O'Connell; Health Inspector�for,the,Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were'observed: 105.CMR 410.100(A) -. Kitchen Facilities—Observed cabinet doors not working properly and one which was missing. 105 CMR 410.351 - Owner's Installation and Maintenance Responsibilities— Observed hole near drain pipe under bathroom sink. 105 CMR 410.480(D) - Locks— Observed slider which could not be locked. Yo' - re.directed-�to corr;ect,.the violations.listed above within.thirty (30)1 days : of -our.recei 't-of this notice b fixiri slidin lass door so that.it locks b repairing Y P Y g g g Y P. g cabinet,doors;-by,-fixing.hole under.sink where drainpipe goes,through wall. You may request a`hearing before„the Board-of Health if written petition requesting same is received within ten (10) days after the date the order is served. QAOrder letters\Housing violations\Rental ordinance\3040 Falmouth Road Fl.doc Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF T E BOARD OF HEALTH omas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Rosemarie L-os & Jen-Grasifa,-Tenants - — - Cc: Timothy O'Connell, Health Inspector QAOrder letters\Housing violations\Rental ordinance\3040 Falmouth Road Fl.doc Ca f ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 ;sl" °f 3 ;- i. ik -,VOILE (781)383-1234 (781)545-2800 (781)749-6178 „n � r- w OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS' ? i i SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A = CERTIFICATION Property Address Franklin Building-Osterville Pines ' 63 0 3040 Falmouth Road Osterville,MA Owner's Name Multiple Owners Owner's Address Huntingest Property Management 40 Industry Road—P.O.Box 340 Marstons Mills,MA 02648 Date of Inspection Completed 1/19/06 Name of Inspector Jeffrey F.O'Connell Company Name Rosano Davis Sanitary Pumping,Inc. Mailing Address 9 Rocky Lane ' Cohasset,MA 02025 Telephone Number 781-383-1234 CERTIFICATION STATEMENT - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ®Passes ❑Conditionally Passes ❑Needs Further Evaluation by the Local Approving Authority ❑Fails Inspector's Signature: Date: 02/08/06 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable and,the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 1 Title 5 Inspection Form 6/15/2000 ROSANO,DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners ' Date: Completed 1/19/06 INSPECTION SUMMARY: Check A,B,C,D or E/AL WAYS complete all of section D; Aj SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.3( exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no or not determined(Y,N,ND)in the_for the following statements. If"not determined"please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed ND explain: 2 Title 5 Inspection Form 6/15/2000 ROSANO,DAVIS 9 ROCKY LANE COHASSET MA 02025 (61.7)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,M.A Owner: Multiple Owners Date: Completed 1/19/06 C Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board or Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water ` Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet of more from a private water supply well". Method use to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3) Other: 3 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1.234 - (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 D System Failure Criteria applicable to all systems: You must indicate either"Yes"or"No" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [The system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO(Yes/No)The system I have determined that one of more of the following failure criteria exist as described in 310 CMR 15.303, fails. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E.Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 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) 4 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (61.7)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION(Continued) Propefty: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 If you have answered"yes to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system with 310 CMR 15.304. The system owner should contact the appropriate,regional office of the Department. Dan@ 1D&ge nM'6eM n0Dn&1My ME DnEMMIk g Title 5 Inspection form 6/15/2000 ROSANO DAMS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (61.7)749-6118 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART B CHECKLIST Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA. Owner: Multiple Owners Date: Completed 1/19/06 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the prevous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were the septic tank manholes were uncovered,opened,and the interior of the septic tank inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum? _ X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System on the site has been determined based on: Yes No X _ Existing information.For example, Plan at B:O.H. X _ Determined in the field(if any of.the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)l 6 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS- 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (61.7)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms(design):. Number of bedrooms(actual): 8 bedrooms. DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Varies. Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No.(If yes separate inspection required) Laundry system inspected (yes or no): Seasonal use(yes or no): No Water meter readings,if available(last two(2)year usage(gpd)): Water usage records were not available at time of inspection. Sump Pump(yes or no): No Last date of occupancy: 01/19/06—Units were still occupied at time of inspection. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd. Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial Waste Holding Tank present(yes or no): _ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER:(Describe) GENERAL INFORMATION PUMPING RECORDS Source of information: Property currently under regular maintenance schedule. Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 1,500 gallons-how was quantity pumped determined?Sight glass on vacuum truck. Reason for pumping: To determine structural integrity and water tightness of septic tank. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool _ Overflow cesspool Privy No Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) No Tight Tank. Attach a copy of the DEP Approval _ Other(describe) Approximate age of all components,date installed(if known)and source of information: System upgraded 5/96 per previous inspection. Were sewage orders detected when arriving at the site(yes or no): No 7 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKYLANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (61.7)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: Franklin Building-Osterville Pines!3040 Falmouth Road Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 1 8 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM = PART C SYSTEM INFORMATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 BUILDING SEWER(locate on site plan) Depth below grade: 22". Material of construction: X cast iron 40 PVC other(explain) Cast iron inlet pipe. Distance from private water supply well or suction line: No known wells in immediate area. Comments:(on condition of joints,venting,evidence of leakage,etc.) All piping appeared to be clean and flowing freely.No evidence of leakage. SEPTIC TANK: YES(locate on site plan) Depth below grade: 12". ' Material of construction: X concrete metal Fiberglass Polyethylene other(explain) 1,500-gallon precast concrete septic tank. If tank is metal, list age Is age confirmed by Certificate of Compliance(Yes or No):_(Attach a copy of certificate) Dimensions: 6'deep X 5'wide X 10.5' long per previous inspection. Sludge Depth: 2". Distance from top of sludge to bottom of outlet tee or baffle: 32". Scum thickness: 3". Distance from top of scum to top of outlet tee or baffle: 8". Distance from bottom of scum to bottom of outlet tee or baffle: 11". How dimensions were determined:Measured with a tape. Comments:(on pumping recommendations,inlet and outlet tees or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) Septic tank was pumped at time of inspection.Inlet tee and outlet tees in place as required.Tank is structurally sound and water tight and all effluent levels were at an appropriate height.There'are no repairs recommended at this time. GREASE TRAP:NO(locate on site plan) Depth below grade: Material of construction: concrete metal Fiberglass Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations,inlet and outlet tees of baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.) .. A 9 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners , Date: Completed 1/19/06 TIGHT or HOLDING TANK: NO.(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal Fiberglass Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm Present(Yes or No)_ Alarm level: Alarm in working order _(Yes/No) Date of last pumping: Comments:(condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES.(If present,must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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 water tight and providing even distribution of effluent.Carryover was moderate.There are no repairs recommended at this time. PUMP CHAMBER: NO.(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.) 10 Title 5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 . (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners -Date: Completed 1/19/06 SOIL ABSORPTION SYSTEM(SAS): YES.(locate on site plan,excavation not required) 'If SAS not-located,explain why: Type: X leaching pits,number: 1—precast concrete leaching pit. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system. Type./name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): There was no surface wetness,breakout or signs of hydraulic failure observed.Leaching appears to be in good working condition. There are no repairs recommended at this time. CESSPOOLS: NO.(Cesspool must be pumped as part of inspection)(locate on`site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: -Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(Yes or No): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: NO{locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) � 11 Title-5 Inspection Form 6/15/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617).749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION.(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road . Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where.public water supply enters the building. , 1 rankMl reQ_/'' �3 - C = Z7 ` A - D = 5 3` 8 _ � _ �� r'= 4-8 ` ; ---�1 cfisfriGufi � b©x leaching pig flo Isca.le 12 Title 5 Inspection Form 6/1.5/2000 ROSANO DAVIS 9 ROCKY LANE COHASSET MA 02025 (617)383-1234 (617)545-2800 (617)749-6178 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART C SYSTEM INFORMATION(Continued) Property: Franklin Building-Osterville Pines/3040 Falmouth Road Osterville,MA Owner: Multiple Owners Date: Completed 1/19/06 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater: Approx.21 feet Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record. If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain:Previous Title 5 Inspection dated 08/02/99. Check local excavators,installers-(attach documentation). Accessed USGS database-explain: You MUST describe how you established the High Groundwater Elevation: During a previous inspection on 08/02/99 the high groundwater was indicated to be approx.21' below grade.This determination was approximated and based on information from the Dept.of Interior Geological Survey and USGS database.It was by this non- intrusive method that it was estimated that separation exists from the bottom of the SAS and the high groundwater. ' t 13 Title 5 Inspection Form 6/15/2000 74 BORTOLOTTI CONSTRUCTION, INC. oF 1999 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 ter. 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: v� Date Of Inspection 7>/e30 f 9!? Inspector's Na we: Ow er's N me and Address: ive CERTIFICATION STATEMENT: I Certify that,I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported•below is true,accurate and complete as of the time of Inspection. The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.Th ystem: Passes" Conditionally Passes Needs Furt val ti By the Local Approving Authority Failure -_..... • Inspector's Signature Date: Y TheSystem,Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Offie of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if.applicable and the Approving Authority. INSPECTI A) SYST PASSES: . I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below., B) SYSTEM,CONDITIONALLY.PASSES: " One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The'Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,•or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or'Breakout or High Static Water Level observed in the Distribution Box is due to ;broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection If(With Approval of the Board Of Health): y ' = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . t Broken pipes)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(sY are`replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. , 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE a SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT.THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH'AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water.supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform , bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• `D)SYSTEM FAI Ss I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due`to an overloaded or clog- ged SAS or"Pool., - Liquid depth in cesspool is less than 6 below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year h=due to clogged or obstructed pipe(s). Number of times pumped -2- i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) t Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to.be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAIIS: . The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply.' The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area InterimVehihead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART B CHECKLIST Check i�the following have been done:t V, Puniping information was requested of the owner,occupant,and Board of Health.- ' None of the system components have been pumped for atleast two weeks and the system has .been receiving normal flow rates during that period. Large volumes of water have not'been introduced into the system recently or as part of this.inspection. —jel—As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. , The site was inspected for signs of breakout. All system,components,.excluding the Soil Absorption System,have been located on site. The.septic:tank manholes wee uncovered,opened,and the interior of the septic tank was in-' it,sPected for condition of baffles or tees,material of construction,dimensions,'depth of liquid, depth of sludge,depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- P} v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(con(inued) V ' The facility owner(and occupants,if different from owner)were provided with information on. the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Bl Design Flow:Reo—gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: A.)d Laundry Connected To System: 00 Seasonal Use: 0 Water Meter Readings,if available: - Last Date of Occupancy: CO MF.R AIAND ST IAL.: j 0 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: _ System Pumped as part of inspection:A,),/) If yes,volume pumped: gallons Reason for pumping: TYP"F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): ROXV"TE AGE of all compo ents,date installed(if known)and source of-information: . - - Sew ge odors de t ed en arriving at the site:A,&) -4- SUBSURFACE,SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: aterial of Construction: ✓concrete metal FRP_Other (explain) Dimisions:/iQ•67;{ &1 k S. Sludge Depth: •,�` Scum Thickness:.. Distance from top of sludge to bottom of outlet tee_ or.baffle: Distance froi bottom of scum to bottom}of outlet tee or baffle: Comments:(recommendation for pumping,condition of inlet and outlet tees or affles,depth of liquid level in relation outlet invert,structural integrity,evidence of I age, etc. GREASE TRAP: '49c) Depth Below Grade: Material of Constnuction: concrete metal FRP Other (explain) Dimensions: - - Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and'outlet tees or baffles;depth of liquid — level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:A) Depth Below Grade: Material of Construction:_concrete_metal FRP_Other(explain) Dimensions: Capacity: gallons Design Flo«-: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note ifIlevel and distribution is equal,'evid of solids carryove ,evidence of leaks a into or out of box,etc. n PUMP.CHAMBER, •.L Pump is in working order`,. -; Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) -5, y� '' .. .. ' .i k'• 4a y."ka.fi iT .yid•Y# � ♦� w - t #a 3` C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods). If not determined to be present,explain: Type: Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comm ts:(note condition of soil,si ns of hydraulic f ilure leve of Pon in condition of vegetation, 04 IF IF CzSSPOOIGs: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication'of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benclunarks. Locate all wells within 100 Feet. 39 DEPTH TO GROUNDWATER: Depth to groundwater: 2/ Feet Meth of Determination or Approxi lion: �'i0 BO C' 1 7.5P ou r t, 7- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Dhipa!3 l Work.6 Tomitrurtiuu Vautit Application is hereby made for a Permit to Construct ( ) or Repair (-K an Individual Sewage Disposal System at: v8 F�L� � ........... ------------------------------------------------------------------------- a `/u d.d�eSssLocatio ...1� t S ..•-•---?�-v �.. ..... .......P --�`...----- � .............................. �dC `y,9 7 cr -7e�G,j M J Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------­3-------------------------Expansion Attic ( ) Garbage Grinder'® aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ................ .............. .. W Design Flow............. ................-gallons per person per day. Total daily flow--------------a.ar7-...............gallons. WSeptic Tank—Liquid capacity/._gallons Length---------------- Width................ Diameter--.------------- Depth................ x Disposal Trench—No. .................... Width................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No......./............ Diameter------/0........ Depth below inlet......6_.-........ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) - . Percolation Test Results Performed by--------- --------------•-----------••-••-----••--...-•------------------- Date........................... --•-•-•--- ,`�� Test Pit No. L...............minutes per inch Depth of Test Pit-------------------- Depth to ground water..... ... 444 Test Pit No. 2................minutes per inch Depth of Test Pit--------------------- Depth to ground water........................ a --------------------------------------------------------------------- ............................................................ •----•--------------------- Descriptionof Soil........................................................................................ ------------------------------------------------------------------••••••.•••--- x W -----•---------------------------------------------------------------------------------------•-••----------------------------------------------....---•------- .... U Nature of Repairs or Alteratio =Answer when applicable-----I Q9 --_-�-:...... ..�.................. ------- -•...00 3 �'L --------— ...... S'>7r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s be n issued pVboard of health. Signed ---------- ......�.... .. _....- '/..- Dace Application.Approved By -------------- ---- --------- --- _ '� Dace Application Disapproved for the following rearons- -------------------- ----------- ----------------- ----------------------------------------------------------------------------- --------- ----------------- ---------------------------------------------------------------------------------------------------- --------------------- ------------- ----------- .............................. .. C 4.., Dare Permit No. ---- 1 - --------------- Issued ......... .._:.Due . Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for DiuVutiul Workii Tontitrurtiun runfit Application is hereby made for a Permit to Construct ( ) or Repair ( >� an Individual Sewage Disposal System at: �6�y U '�7t�vvt UtrT x �/ 1i. 6 ----- ----------------------�':......_...-•-----•-......---••-••----......--------•-----.._... Location-Address or Lot No. - vim,(= ' ?`) ` U Na vim';iLy .!Zo. D ---------------------------•--. •-•-•-•----._._...-----.....------••- Owner -76 Address a Installer Address j � Type of Building Size Lot______ S_____________________ q. feet Dwelling— No. of Bedrooms-------------�---__._---_---_--_--.--Expansion Attic ( ) Garbage Grinder_(---).A f 0 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- w Design Flow................ --- --------._- w..................gallons per person per day. Total daily flow---------------3r�...............gallons. -- WSeptic Tank—Liquid capacity/q-� _galIons Length---------------- Width------.-.--.-.-- Diameter_..-._-_._.... Depth................ x Disposal Trench—No. .................... Width___..-7---..-------. Total Length------.....__�__-.._ Total leaching area.................... ft. Seepage Pit No--------/.......... Diameter-----.O-.--.-- Depth below inlet------6.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •-••---------••--------------•••--•••-••--------•-••------••---•----•-••--•......•--...._......-----......................................................... 0 Description of Soil......................................................................................................................................................................... w UNature of Repairs or Alterations—Answer when applie�ble.-..-! ✓ �w -...--------_-- �'_.. ?fl, /h-. ..._:�/�__i , Gam_.. --------�Gl.-U S rrT- w�• f-`, 7"G Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s ben issued t47board of health. Signed . ------ ---�---��/��------ ODace Application.Approved By ............... �C1 ---- _ .�...:.? . : „*,....e $ -c_ -..��................._--------------.............-'-------'---- Dace Application Disapproved for the following reasons: ................ ._ ............. ..................... ...................... .. ... .. -- . ----------------------------------------------------------------------------------------------------- --------------------------- ------------------------------------------------------------- ........................................ Dare Permit No. ------9._5 ........'r .L�-..-------- issued-..:........ _.-_D_C-- '-- ......_. Dare r , THE COMMONWEALTH OF MASSACHUSETTS } BOARD OF HEALTH TOWN OF BAR((..��NSTABLE Certificate of Contylialtric W THIS IS TO CURT-IR,Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (x ) by -------------------------------- ,� --- ------- _-------------------------------..----- ---------- . t - ' JLD� G5� � at ----------- 3® C ^------ --------- - -- . . ... u has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... `*�._—..? - ...- dated ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION DATE- � SATISFACTORY. r � 1 r ., - ' --- ----- - Insect o.-� ".'-T.T� '- - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9 �j TOWN OF BARNSTABLE—V 4 L j FEE. Dwposal Workii Tunotrnr#uan f amit Permissionis hereby granted • --••---•••-••------•--•---•----•--•---------•-------------'-._......_...---•-•••-----•......................... to Construct ( _ or Repair (�< an Individual Sewage Dis osal................................... ystem `-- at No.•••-•-•---•-•--�..--y�---------- uv �•.... r �.J1Lu^1 ,COG ._. --- Street C � `� as shown on the application for Disposal Works Construction Permit No._,/ __,.._-__ Dated____--___,�_-:'�E.-------/ y1. .... ......................... �.. , . Board of Health DATE �` = -�------•--•--- FORM 36508 HOBBS R WARREN.INC..PUBLISHERS