HomeMy WebLinkAbout3040 FALMOUTH ROAD/RTE 28 - Health (5) 3040 Falmouth Road, Osterville _1I
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Commonwealth of Massachusetts
a- IF Title 5 Official Inspection Form
lip Subsurface Sewage Disposal System Form Not for Voluntary Assessments .
,• 3040 Falmouth Road Bld F
V�
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills I✓ MA 02648 09/10/2020,
page. City/Town State Zip Code Date of Inspection
� E
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. Inspector Information : (,* (Lf(6+9
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.
Ali
� 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
09/14/2020
Inspector's tignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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
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Commonwealth of Massachusetts
il-� Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
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:
This 8 bedroom condo building has an H-10 1500 gallon septic tank with an H-10 D-Box feeding a
precast leaching pit with stone. At the time of the inspection no visible failure criteria was 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
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r
Commonwealth of Massachusetts
,- Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u � 3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town 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 Bid F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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
V 3040 Falmouth Road Bid F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® 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
'4
❑ ❑ 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms (actual): 8
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 plus
GPD
Description:
I
ti
I
I
Number of current residents: apx 7
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 ears usage town water
9 ( y 9 (gpd))�
Detail
see attached
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
I
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form ,
1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
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 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: The tank is scheduled to be pumped after the
inspection
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
L
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 3040 Falmouth Road Bid F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
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):
I
Depth below grade: 36"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 flowing during the inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 24"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: H-10 1500 gallon
Sludge depth: 51f
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness 3„
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
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.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. 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
Title 5 Official Inspection Form
I
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... , !% 3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
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
I
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 3040 Falmouth Road Bid F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
{
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
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
+_ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. City/Town 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. Cityrrown 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
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
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
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I
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3040 Falmouth Road Bld F-cf
Property Address
Osterville Pines Condo
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 09/10/2020
page. City/Town 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
Back
A B
Oi A B
0 1 22'5" 24'
2 27'4" 307'
3 38'6" 48'
1,2, 3—have steel
Ocovers to grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1s of 1s
h
Commonwealth of Massachusetts
,�-p Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 16 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
I augered a hole to 16'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
i
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 3040 Falmouth Road Bld F
Property Address
Osterville Pines Condo
Owner Owner's Name
information is required for every Marstons Mills MA 02648 09/10/2020
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
April 2011
TOWN OF Barnstable
Board of Health
200 Main Street
Hyannis, MA 02601
RE: Lifeguard Modification for Outdoor Pool
Osterville Pines Condominium
Location: 3040 Falmouth Rd., Marstons Mills
The Condominium requests a variance of Lifeguard Modification for Qualified
Swimmer.
The Condominium is Private Property, Residents Only and the pool is supervised
at all times the pool is in use. The pool is padlocked when a Qualified Swimmer
is not in attendance.
The CPO is Oceanside Pools.
CPR certificates are on file with the Board. New certificates will be forthcoming
as soon as completed.
Please find attached Insurance Liability Certificate.
Huntingest manages the property and is the proper mailing address.-
Thank you,
Ja JCurtis
Huntingest Management
PO Box 340
Marstons Mills, MA 02648
508-428-1112
Enc: 1
ACORD,. CERTIFICATE OF PROPERTY INSURANCE DATE
3/30/2011
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Commercial- ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
233 West Central Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Natick MA 01760 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY Norfolk & Dedham Mutual Fire
A
INSURED COMPANY
Osterville Pines Condominium Trust B
c/o The Huntingest Group
PO BOX 340 COMPANY
Marstons Mills MA 02648 C
COMPANY
D
COVERAGES
HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED;'NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE
Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND
ONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICVEFFECTIVE POLICY EXPIRATION
LTR TYPEOFINSURANCE POLICVNUMBER COVEREDPROPERTY LIMITS
DATE(MM/DD/VV) DATE(MM/DD/YY)
A Xj PROPERTY R0644425A 1/l/2011 1/1/2012 BUILDING $
CAUSES OF LOSS PERSONALPROPERTY $
BASIC X BUSINESSINCOME $150 540
BROAD EXTRA EXPENSE $
X SPECIAL X BLANKETBUILDING s2, 874,000
EARTHQUAKE BLANKET PERSPROP $
FLOOD BLANKET BLDG&PP $
NX Repl Cost $
X $10 000 DED
$
INLAND MARINE
TYPE OF POLICY $
CAUSES OF LOSS $
NAMED PERILS $
OTHER
A X I CRIME R0644425A 1/l/2011 1/1/2012 X Empl Dishon $50 000
TYPE OF POLICY X Empl Dls ded $1 000
Employee Dishonesty X Theft $15 000
BOILER&MACHINERY $
X OTHER Occurrence $1, 000, 000
A General Liability R0644425A 1/l/2011 1/1/2012 Gen Aggregate $2,000,000
LOCATION OF PREMISES/DESCRIPTIONOFPROPERTY _
3040 Falmouth Rd (Rte 28) Osterville, MA 02655 (43 Unit Residential Condominium)
Town of Barnstable is named as an additional insured on the General Liability policy re: swimming pool.
SPECIAL CONDITIONS/OTHER COVERAGES „
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
Town, of Barnstable BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY
367 WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
Main Street CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL
Hyannis MA 02601 SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY
BIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REP RESENTATIVE;
ACORD 24(1/95) p ACORD CORPORATION 1995
i
�i 1752
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m , d DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
DEC 10 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION MAR V
Property Address: 3040 Falmouth Rd,Osterville,Osterville Pines,Bldg G PARCEL'
4
LOT
Owner's Name: Huntingest Management(Osterville Pines Condo Trust)
Owner's Address: Unit#c,40 Industry Road,Marstons Mills,MA 02648
Date of Inspection: 11/07/03
Name of Inspector: Brian T.Axon
Company Name: A&K Septic Systems Plus
Mailing Address: 565 Carriage Shop Road East Falmouth,MA 02536
Telephone Number: 508-540-6706
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and.complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally,Passes
Needs Further Evaluation by the Local Approving Authority .
Fails
Inspector's Signature` Date: 11/12/03
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments: System functioning fine. There are no violations of failure criteria. System consists of 1500
gallon tank,D-box and 1 6' x 10' leaching pit.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
I
f
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Bldg G,Osterville Pines,Falmouth Rd,Osterville,MA
Owner: Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03 r
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303
or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: r
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):'
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
,ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART A
CERTIFICATION(continued)
Property Address: Bldg G,Osterville Pines,3040 Falmouth Rd.,Osterville,MA
Owner:Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh'
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS'is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well`*.Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
r
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:Bldg G,Osterville Pines,Falmouth Rd.,Osterville,Ma '
Owner:Huntingest Management(Ostervile Pines Condo Trust)
Date of Inspection: 11/07/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than''/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 high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
r;
h:
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Bldg G,Osterville Pines,Falmouth Rd,Osterville,MA
Owner:Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection:11/07/03
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
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 all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:Bldg G Osterville Pines,3040 Falmouth Rd,Osterville,MA
Owner: Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual):4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 6
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): no
Seasonal use: (yes or no):no
Water meter readings,if available(last 2 years usage(gpd)):NA
Sump pump(yes or no):no
Last date of occupancy: current
COMMERCIALANDUSTRIAL
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: System on regular maintenance schedule,project manager
Was system pumped as part of the inspection(yes or no):no
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption`system
_Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank !Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: 20+years,town hall
Were sewage odors detected when arriving at the site(yes or no):NO.
Page 7ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Bldg G,Osterville Pines,Falmouth Rd.,Osterville,MA
Owner:Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03
BUH.DING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK:x (locate on site plan)
Depth below grade: 2'
Material of construction: x concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of .
certificate)
Dimensions: 10'6"x 57"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 34"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined:Field instruments
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Recommend pumping every two years. Tees liquid level in relation to tees and structural integrity are all fine.No
evidence of leakage.
GREASE TRAP: NA(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
I
Page 8of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Blg G,Osterville Pines,Falmouth Rd,Osterville,MA
Owner:Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: x (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to'outlets equal,any evidence of solids carryovers any evidence of
leakage into or out of box,etc.):
Distribution equal.No evidence of solids carry over.No evidence of leakage.
PUMP CHAMBER:NA(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
G
Page 9 of 11 ;
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS °
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Blg G,Osterville Pines,Falmouth Rd.Osterville,MA k
Owner: Huntingest Management(Osterville Pines Condo Trust) ,r ,
Date of Inspection: 11/07/03
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
Typ
X e leaching pits,number: 1 T ~
leaching chambers,number: ;
leaching galleries,number: 4
leaching trenches,number, length:' �..:
leaching fields,number, dimensions: .
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, -
etc.):
Condition of soils and vegetation fine.No evidence of hydraulic failure.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: k
Depth of solids layer: '
Depth of scum layer.-
Dimensions of cesspool: „
Materials of construction:
Indication of groundwater inflow(yes or no). ;
Comments(note condition of soil; signs of hydraulic failure,level of ponding,condition of vegetation,etc):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions: i
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
t
t.
,
f
Rage 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Bldg G,Osterville Pines,Falmouth Rd,Osterville,MA
Owner: Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03
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.
0
CI 1l �a v?f S
E
� J
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Bldg G. Osterville Pines,Falmouth Rd,Osterville,MA
Owner: Huntingest Management(Osterville Pines Condo Trust)
Date of Inspection: 11/07/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 1y+feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
x Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
x Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
New leaching installed at Bldg.D.No groundwater at 1)t'.
���1 4a�U�r•�,='`�-�'' '.. it � !.
1
1," N
q
N 'bTOWN OF BARNSTABLE � 'boo
BOARD OF HEALTH
�o
ARTICLE I1:MINIMUM STANDARDS FOR HUMAN HABITATION
Date
Owner Tenants``
Address '�� '� � t _-�"'�Ae�" Address
Complionce Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities �� �
Ive 1092z�rale fgr 0 -c
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
ej r-
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use ?/
12. Exits
13. Installation and Maintenance of Structural F / 67�
Elements z L�
14. Insects and Rodents 1'LZ ��vr
15. Garbage and Rubbish Storage and Disposal5 -
16. Sewage Disposal aw vq
17. Temporary Housing f
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants;Demolition
' J
Person(s) Interviewed t Inspec
If Public Building such as Store or Hotel/Motel specify here
HOBBS$WARREN.INC.
k
MRVP #
Assessor's office (1st Floor)
Assessor's `d Parcel # L
Building epar
Zoning
INSPECTION FEE $50.00
RE-INSPECTION FEE $15.00
Request For A Housing Inspection For Certification Under the
MA Rental Voucher Program
Your Name
Affiliation (Circle One) Owner Real Estate Agent enant,
Your Address ,'F0" 7�W Z- `MA
Telephone Number (Day) (Night
)
Address of Property Where Inspection is Requested
Unit/Apt.# 9
A
Name of Owner �'�� lQZ
Address - - � f� ��- ems✓ � ��3 1
Mailing Address (if different)
Telephone Number (Day) (Night)��_--'_ �
Will there be any children under the age of six (6) who will
be occupying the rental unit? (circle one) Yes N3�
Was the dwelling constructed prior to 1979? rYes5 No
------------------------------------------------------------
FOR OFFICE USE ONLY:
Certification
The dwelling, dwelliUq unit, or rooming o ated at
V o ,z wwa, inspected on
l- >z by Health
Inspector for the Town of Barnstable and was fou d to be in
compliance with the provisions contained within 105 CMR
410.00, State Sanitary Code II: Minimum Standards of Fitness
for Human Habitation. However, this certification does not
include a determination as to whether this unit contains any
lead paint because under 760 CMR 49.02 Massachusetts Rental
Voucher Program, a separate lead paint inspection must be
conducted.
Inspector's SignatIlte ��
Date ` G
.�.a .."^a'+.s'i..,.r;Y�rw.ti- 4i`�..+t w...., +.wv..Y-..e r. "'4+�,+•r.-... '•+v+`va.•.,�.-R'._-. -u th+,*iytj-�•• •.«.. ., `s.P' '(�?of:i47C;�',.�...�'ii:'�.y,,.��.4 ,'^ h'"hc--i:""^'°�s,. ,C..
,a
MRVP #
Assessors office (1st Floor)
Assessor's a�-and Parcel #
Building epar, nt (4th+1�or)
.
Zoning or
INSPECTION FEE $50.00
RE—INSPECTION FEE $15.00
Request For A Housing Inspection For Certification Under the
MA Rental Voucher Program
Your Name
Affiliation (Circle One) Owner' Re 11 al Estate Agent A�ant
Your Address �b" !/:�/� � p l ✓ r za�,�
Telephone Number (Day) (Night)
Address of Property Where inspection is Requested
Unit/Apt.#
Name of Owner
Address
.y� Mailing Address (if different)
Telephone Number (Day) (Night - ~
t
Will there be any children under the age of six (6) who will
be occupying the rental unit? (circle one) Yeses:.`
Was the dwelling constructed prior to 1979? Ye' No
t .
---------------------------------------------------------
FOR OFFICE USE ONLY:
Certification
The dwelling, dwelling unit, or rooming u Lt/ ocated at
w s inspected, on
1•. by Health
Inspector for. the Town of Barnstable and was found to be in
compliance -with the provisions contained within. '105 . CMR
410.00, . State Sanitary Code II: Minimum' Standards of Fitness
for Human Habitation. However, this certification does' not
include a determination as to whether this unit contains any
lead paint because under 760 CMR .49.02 . Massachusetts Rental, •
' Voucher Program, a separate lead 'paint inspection must be
conducted.
' Inspector's Signat e
Datet
t !r1:S r.wM�l:r"Fx}�ry T�`y+.""+•i.e, .1�A.
e1 p_
�i
3 P
N4 � hod
BORTOLOTTI CONSTRUCTION, INC. 9`9,9
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508428-8926 FAX: 508428-9399
• Z l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
R ¢CERTIFICATION '
Property Address:
Date of Inspection: /O�9 Inspector's N<me:
Ow er's are and Address: � O
U ,4
CERTIFICATION STAT ENT',,
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 inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage,
disposal systems. The System: F
1� Passes .
Conditional) 'y Passes
Needs Further Ev. tion v Local Aproving Authoruty
Fails
Inspector's Signature:: ✓(t' �l1 ate:' °
... .. a ..a .
. ,
The System Inspectoushall submit`a"copy of[Itis'inspection report to the Approving authority within thin-
ty.(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"eport to the appropriate regional ,
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if-applicable and the approving authority.
INSPECTION IMhIARY
,
/ t
A)SYST'F�I PASSES:
VVV I have not found any information which indicates that the system violates"any,qf the"failure
criteria as defined in 310 CIR 15.303, Any failure criteria not evaluated are indicated
below.
...
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple
.don of the.replacement or repair,passes inspection
Indicate yes, nor,or not determined.(Y,..N,OR ND). Describe basis of.determination i,n all instances. If
"notdete .
rmnmmied",rexplamn why_not ,:,��x��. �j$p ..:�:x. • .< �_ . .
;The tic:tank-;is.metal,>cracked, sfructurally unsound,shows substantial infiltration'oi'
f seP ,
exfiltration,or tank failure is imminent. The system will.pass,inspection if the existing sep-�. w. , _ -
i1 =tic tank.is replaced with'!confornung.septic tank-as-approved by The Board of Health.
`' ` Sewage backkup orrbreakout orhigh 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
w .
system will-pass inspection if(with approval of The Board of Health):. i
�i
j
t ;
17
T.EM INSPECTION FORM
+'» ;�t� ; _ . ;SUBSURFACE SEWAGE DISPOSAL SYS s.•Y
� PART A
;CERTIFICATION(continued)
•r � x
Broken pipe(s)replaced
Obstruction is"removed
Distribution Box is levelled or replaced
in mor
e than four times a year due to broken or obstructed pipe(s).
um Y
The System required g
Y
pumping
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION.IS REQUIRED BY THE BOARD OF HEALTH: .
Conditions.exist which require further evaluation by The,Board of Health in order to determine if
the system is failing to.protect the public Health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROT
ECT
T 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
TE, DETERMINES THAT,THE SYSTEM IS`FUNCTION-
IF..APPROPRIA )
SUPPLIER, .r ,
ING,IN;A MANNER THAT PROTECT PUBLIC HEALTH AND SAFETY AND THE
,. - .. .... t r .:,: ?fie .. • ., 1':"� rd1 E e'4 ,
The systemhas 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 aseptic tank and soil absorption:system an is with a Zone I of a'public
water supply well.
The system has a septic tank and soil absorption system and is'within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than-5"ppm,
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in-the'distribution box above outlet,invert due,to.an overloaded or clog-
ged SAS or cesspool,.
` '- iLigind depth infcesspool 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,M, -due to clogged'or obstructed
pipe(s). Number of times pumped
2-
,4
• r
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "T
p PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy i§below the hi ah groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply outributary 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 coliPorm'bacteria,'volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS: i
The following criteria apply to a large system in addition to.the'criieria'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:,.
y 4 The system is within 400 Feet of:a surface drinking water supply 0
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
y (IWPA)-or a mapped Zone l:1 of a public water-supply
The owner or operator of any such system shall bring'the systerii aiid facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00'and 6.00:•Please consult the local
regional office of the Department for further information. `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if I to following have been done::
,/Pumping informatiou,was requested of the owner, occupant,and Board of Health.
✓ None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
As-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_✓ The system does not receive non-sanitary or industrial waste flow..t
_ 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 were uncovered,opened,and the;interior of the septicIank was in-
4 -,.spected'for'conditioWof baMes.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
oc " t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.. PART B
�CHECKLIST.'(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION "
t FLOW CONDITIONS
RFSIDENTL�►�� � �
�)
Number of Current Residents:O� .
Design Flow._�30 ggallons Number of Bedrooms: � Nu _�
Garbage Grinder: A<)y Laundry Connected To System: ,JC) Seasonal Use: A)()
Water Meter Readings,if available: '
Last Date of Occupancy:
rn�r dERCLAIANDLiSTRi_Ai.:
Type of Establishment:
Design Flow: gallons/day.r.!Grease Trap Present: Qes.or no)
Industrial_Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Daie of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: -
System Pumped as part of inspection: a( U If yes,volume pumped:_ gallons
Reason for pumping: -
Sptic
F SYSTEM:
Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records; if any)
Other(explain):
APPROXIMATE AGE of all components,date installed(if known)and source of•'information:
.. . +"
AA-
._$ewage od detected when arriving at the.site: - 0
SUBSURFACE SEWAGE DISPOSAL,SVSTEM INSPECTION FORM
`. . PART C
GENERAGINFORMATION (continued)
SEPTIC TANK:'.',
Depth below grade: �)4o "' Material of Construction:'Y-concrete metal FRP Other
(explain) —
Dimisions:j0•S'X&'X S/ Sludge Depth: 9 " Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3,
Distance from bottom of scum to bottom of outlet tee or baffle: j " --
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid
level(iinnrelatio to outlet invert,structural inte ity,evi nce of I akage,etc. A 0—/OVD
GREASE TRAP: %(�d
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) - — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or biflle:
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?); :},,.:
u
TIGHT OR HOLDING TANK: lid
Depth Below'Grade: Material of Construction—concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons, Design Floc:` s.allons/day ,
Alarm Level:
Comments: (condition of inlet tee, condition of alarm and float switches..etc.)
DISTRIBUTION BOX: r�
Depth of liquid level above outlet invert: P
Comments: (note if 1 el and distribution is equal, eviden a of solids carryover, evidence Neocage into
or out of box,etc.)
/4 - ct.� i�n_ �`1
PUMP:CHAMBER.A (J.
PPMP,is in wo in order:
,.
rComments:_.(no(econdition of pump cfiarnber, condition ofrpumps and appurtenances, etc.).
-
,� .. i di tat �,,���,��^����.. � fi �x '�7 � • ' �G
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPEC'TION FORM
PART.C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS): V
(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: J Leaching chambers,number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Co ts: (note condition of soil,signs of hydraulic fail a level of nding,condi 'on of vegetation,
etc. /OGY�
CESSPOOLS:
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 soilic,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY: �J
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6
Jy
7 SUBSURFACE SEWAGE DISPOSAL SYlt'STEM.INSPECTION FORM .
_. .. PART C
r SYSTEM INFORMATION(continued) '
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks."*
Locate all wells within 100 Feet.
a I
Xi
DEPTH TO GROUNDWATER: ,
Depth to groundwater: / Feet ;
Method o termination or ppro lion:
0 l` �
vu
-7-
aa,k30' jf
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Tow�rc�Y Bar stable
Public Health Division
$ 200 Main Street
9..+° Hyannis,MA 02601 '_": .r ` 07
7 7'= TWEY 60VjYCSny
02 1 A $ 00:390'
0004606238 APR25 2007
MAILED FROM ZIP CODE 02601 1
1; J C4!
Ea� G)� v
Qz
L
4 c NX,XIF- 0229 1 00 04.r2 .f07
RETURN TO SENDER
NO MAIL. RECEPTACLE
UNADLE TO FORWARD
DC: 02801400200 *292.2-07581-2.5--39
Alt�4002
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'I
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Certified Mail#7006 0810 0000 3524 9711
�P oFTE taw o Town of Barnstable
. Regulatory Services
BARNYMBLE, "
9a aaAM- Thomas F. Geiler, Director
O 0,39.
RFD MAC a. Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 23, 2007
Glen Liset
9 Deacon's Path
Sandwich, MA 02563
NOTICE Tb ABATE°`VIOLATIONS°'OFx 105'CMR`=`410`.00'OSTATE -SANITARY
CODE II'•-M.-INIMUM--STANDARDS"OF FITNESS FOR HUMAN;HABITATION
AND=THE.TOWN•OFLBARNSTABLE CODE,.CHAPTER-170
The property owned by you located at 3040 Falmouth Road J2 Marstons Mills, was
irigpected on;April.22-- 007-by; Meredith.,Morgan, 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 410.480—Locks. Sliding door lock broken; screen door broken.
The following violations of the Town of Barnstable Code were observed:
17§ 0-10---S:moke,Detectors and Carbon;Monoxide Alarms No,CO detector. .-
fF(a.. '. ...S
Youfare d><rected to correct thexv><olattons 1>Lsted abovew><th>In twenty-four (24) hours
of your receipt of th><s{not><ce by mstallinO tector: You ar g.0 e"drected to correct;
de
'the violations listed"above within tliirty'(30) daysof your;receipt:ofthis iotceby _;,Y
fixing or replacing sliding door lock and broken screen door.
QAOrder letters\Housing violations\Rental ordinance\3040 Falmouth Road J2.doc
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.
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.
4PER ORD + OF TH BOARD OF HEALTH
as A. Mc ean, R.S., CHO
Director of Public Health _
Town of Barnstable
Cc: Meredith Morgan, Health Inspector
Cc: Bob Grindrod, Tenant
i
QAOrder letters\Housing violations\Rental ordinance\3040 Falmouth Road J2.doc