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Commonwealth of Massachusetts 099,b30-oz)A
,F Title 5 Official Inspection Form
I" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rr
M Osterville Pines--3040 Falmouth Road,Osterville, MA BUILDING"B"
Property Address C`
Multiple Owners '
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19 -
page. Cityrrown State Zip Code Date of Inspection cq
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 6�#f` f,3l�Q
filling out forms -/
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
Company Address
Cohasset MA 02025
Cityrrown 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. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
03/26/19 _
Inspector's Si ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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
T
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 "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 03/20/19
page. CityTrown 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 i
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
L'
,ip Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
o
M Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville, MA 02655 03/20/19
required for every �
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 FIND(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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 03/20/19
page. CityrFown 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:
p
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
ElDischarge 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
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "B"
u Property Address
Multiple Owners
Owner Owner's Name
information is Osterville, MA 02655 03/20/19
required for every �
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 Y2 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 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. i
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
❑ z 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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for every �
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
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
page. Cityrrown 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 gpd
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 Z 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 pf 18 ,
r Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
l
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owners Name
information is O
required for every sterville, MA 02665 03/20/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: 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.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4 Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/20/19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Previous inspections indicated installation in 1995 by Bortollotti.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
36"
Depth below grade: feet
Material of construction:
El 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 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
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"B"
Property Address
Multiple Owners
Owner Owner's Name
information is
required for every Osterville, MA-. 02655 03/20/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 24"w/covers to grade on inlet
and outlet.
Material of construction:
Z 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:
6'wide x 5'deep x 10.5' long
Sludge depth: 5,o
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness 3.,
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
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.
I
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
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 "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville,. MA, 02655 03/20/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
I
❑ 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
c 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"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for every �
page. CitylTown 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.):
i
*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 0..
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box was structurally sound and watertight and providing even distribution of effluent into
SAS. Carryover was moderate.There are no repairs recommended at this time.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Osterville Pines-3040 Falmouth Road, Osterville; MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osteryille MA 02655 03/20/19
page. Citylrown 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
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ in 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
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owners Name
information is required for every Osterville MA 02655 03/20/19
page. CityrFown 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.Top of pit is down approximately 38"
with cover to grade.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
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
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 03/20/19
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.):
i
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
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 "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville,
required for every MA 02655 03/20/19
page. Citylrown 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:
Z. hand-sketch in the area below
❑ drawing attached separately —�
i
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C3 as'
3 So'6"
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18
— I
Commonwealth f
,a
o Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
MV Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 03/20/19
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: 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 propertylobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Previous inspections.
i
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
During previous inspections the high groundwater was indicated to be 22' below grade.This
determination was by USGS groundwater maps. The bottom of the pit is 9.5' below grade per
previous inspections. It was by this non-intrusive method that it was estimated that separation
exists from the bottom of the SAS and the seasonally high groundwater elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.,
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 .
' I
1. 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"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/20/19
required for every �
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 N. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Obtained from USGS maps. \
I - - �31'
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 18 of 18
' I
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. City/Town State Zip Code Date of Inspection
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 i
key.
Rosano Davis Sanitary Pumping, Inc.
VQ Company Name
9 Rocky Lane
Company Address
few
Cohasset MA 02025
City/Town State Zip Code
781-383-8888 SI49
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
—X 09/25/14
Inspector's 8Wnature 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.
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
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
W Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING'B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
D. System Information
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.
i
Sump pump? ❑ Yes ® No
Last date of occupancy: Building
occupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
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 "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
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 semi-annual pumping
schedule.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,600 gallons i
gallons
How was quantity pumped determined? Sight glass on pump truck.
Reason for pumping: To determine structural integrity and
watertightness of septic tank.
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 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
yl a Osterville Pines -3040 Falmouth Road, f Osterville MA BUILDING"B"
�M
Property Address
Multiple Owners
Owner Owner's Name
information is terville,Os
required for every MA 02655 09/18/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Previous inspections indicated installation in 1995 by Bortollotti.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 36"tee"
Material of construction:
I
❑ cast iron ® 40 PVC ® other(explain): Schedule 40 PVC inlet pipe.
Distance from private water supply well or suction line: No known wells in immediate
area.
Comments (on condition of joints, venting, evidence of leakage, etc.):
Inlet pipe appeared to be clean and flowing freely. No evidence of leakage.
Septic Tank(locate on site plan):
Depth below grade: 2'w/covers to grade on inlet and
outlet.
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Precast concrete septic tank.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
6'wide X 5'deep X 10.5' long.
Sludge depth:
3"
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
°M s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville, MA 02655 09/18/14
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
35"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
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 are in place.There are no
other repairs recommended at this time.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Offic'al Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. City/Town State Zip Code Date of Inspection
D. System Information (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-3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box was structurally sound and watertight and providing even distribution of effluent.
Carryover was moderate. There are no repairs recommended at this time.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required).-
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING'B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 09/18/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
There was no surface wetness or breakout observed.There were no signs of hydraulic failure
observed. SAS appeared to be in proper working condition.Top of pit is down approximately
38"with cover to grade.There are no repairs recommended at this time.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02665 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
I
t5ins•3113 Title 5 Official Inspection Forth: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-3040 Falmouth Road, Osterville, MA BUILDING "B"
Property.Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Rau r a-P
Q Q �
Ll
008
❑
VA 9
O
3
Al
3 ya`
a 37
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 -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owners Name
information is Osterville MA 02655 09/18/14
required for every �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: SEE BELOW
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Previous inspections.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
During previous inspections the high groundwater was indicated to be 22' below grade.This
determination was by USGS groundwater maps. The bottom of the pit is 9.5' below grade per
previous inspections. It was by this non-intrusive method that it was estimated that separation
exists from the bottom of the SAS and the seasonally high groundwater elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M Osterville-Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 09/18/14
required for every � .
page. Cityrrown State Zip Code Date of Inspection
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
Obtained from USGS maps.
I � �
f
\A,L H C�GZovrJ��
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System F rm-Not for V lu ry Assessments
Osterville Pines -3040 Falmouth Road; Ile, MA BUILDING-�'B'
Property Address
Multiple Owners,
Owner Owner's Name
information is t ( I S MA 02655 03/02/11
required for every �` ft
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 filling out forms A. General Information /
( �I
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
03/15/11
Inspector's4fignature 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.
1page
t5ins 09/OB R n V� Title 5 Official Ins ection Form:Subsurface Sewa a Dis osal .st� 1 of 17
osa o Da rs Sanitary Pumping,tnc 781-383-8888 P P
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-
M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every
page. Cityrrown State Zip Code • Date of Inspection
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:
l 4
❑ 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.
El Y ❑ N ❑ ND (Explain below):
t5ins-09108 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02111
•
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑' N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
a
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further,evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessment's
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address ,.
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) k
2. System will fail unless the Board of Health (and-Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: _
❑ The system has a septic tank and"soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply:
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet'of a private water
supply well.
❑ The system has a septic tank and SAS and the,SAS is less than 100 feet but 50 feet or
more from a private water supply well**. -
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other: t
• F
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of•the following for all inspections:
•Yes No
b
' 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
5 ❑ ® 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 Jess
than Y day flow
t5ins•osim Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
a
f .
}
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name - •_
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 groundwater 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 11 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) L'arge 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 eithee"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
T
f
❑ ❑ 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•ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every -
page. Cityrrown State Zip Code Date of Inspection
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?
a
® ❑ 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:
s
® ❑ 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)]
M System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based onn310 CMR 15.203 (for example: 110 gpd x#of bedrooms)-' 440 god.
t5ins-Os/Oa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 .Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0 Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Unknown.
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ .Yes ® No
Laundry system inspected? ❑ Yes ❑ No
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
03/02/11 =
Last date of occupancy: Building occupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
+Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•ogios Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 '03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: , Date
Other(describe below):
r General Information
Pumping Records:
Condo Association on yearly maintenance
Source of information: schedule.' '
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,500 gallons
gallons
How was quantity pumped deter"mined? Sight glass on pump truck.
Reason for pumping: Yearly maintenance&to determine structural
integrity &watertightness of septic tank.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool ,
❑ 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•09io8 Rosano Davis Sanitary Pumping,Inc - 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°,M s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Installed in 1995 by Bortollotti per previous inspection.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC El other(explain): Schedule 40 PVC inlet pipe.
Distance from private water supply well or suction line: No known wells in area.
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
All piping appeared to be clean and flowing freely. No evidence of leakage.
Septic Tank(locate on site plan): '
j
2'w/cast iron covers to grade on
Depth below grade: inlet&outlet.
Material of construction:
® concrete ❑ metal ❑fiberglass• ❑ polyethylene ❑ other(explain)
Precast concrete septic tank.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes .❑ No
Dimensions:
6'wide X 5' deep X 10.5'_long.
Sludge depth:
t5ins-o9ioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.). -
• r
Septic Tank(cont.)
'
Distance from top of sludge to bottom of outlet tee or baffle• •35",
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
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 was pumped at time of inspection. Tank was structurally sound and watertight and
all effluent levels were at an appropriate height. Inlet and outlet tees in place. There are no repairs
recommended at.this time. .
Grease Trap (locate on site plan):
Depth below grade: y;
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
.. 1
Dimensions:
Scum thickness
A to •
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.09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17.
,t
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 "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. City(rown 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 El 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•ogroa Rosano Davis Sanitary Pumping,Inc 781-383-8888 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 -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655- 03/02/11 .
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0" r
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: El Yes y ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System'(SAS) (locate on site plan, excavation not required):
-If SAS not located, explain why:
l5ins-o9toa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02665 03/02/11
page. CityrFown State . Zip Code Date of Inspection
D. System Information (cont.) .
Type: r
1 -6'X 10'
® . leaching pits number: leaching pit.
❑ leaching chambers number:
El 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. Top of pit is
down approximately 38"with cover to grade. Leaching appears to be in proper working condition.
There are no repairs recommended at this time,.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer ,
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
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 "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
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.): _
I
t5ins-09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
{
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is Osterville MA 02655 03/02/11
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) ,
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
- Qvctr off' ld�. 13
A a
b
O
3
Al
3 Li
• - a 3�,Ga
3
t5ins•I'ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts K
Title 5 Official. lnspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners �.
Owner Owner's Name ,
information is required for every Osterville MA 02655 - 03/02/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
X _
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 4
Estimated depth to high ground water: SEE BELOW
feet
Please indicate all methods used,to determine the high ground water elevation: ,
❑ Obtained from system design plans,on record
If checked, date of design plan reviewed: Date'= _
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Previous inspections.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain: "
- F
You must describe how you established the high ground water'elevation:
During a previous inspection the high groundwater was indicated to be 22' below grade.This
determination was obtained from USGS maps.'The bottom of the pit is 9.5' below grade per
previous inspection. 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.
g
t5ins•09108 Rosano Davis Sanitary Pumping,Inc 781-383-8888 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "B"
Property Address
Multiple Owners
Owner Owner's Name
information is required for every Osterville MA 02655 03/02/11
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist -
® 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
i
Obtained from USGS maps.
,
- I 3gr �p •
• � •' . � ._ Ate.
t5ins•0§i08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 `
r
�-
•
COMMONWEALTH OF MASSACHUSETTS 3/�9/as
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF R iA; B ATrZNSTABt.E
µ d DEPARTMENT OF ENVIRONMENTAL PROTECTION
ARCELO,� V0V
014r IS108
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:3040 Falmouth Road,Osterville Pines,Bldg B
Owner's Name: Osterville Pines Condo Trust,c/o Huntingest Management
Owner's Address: 40 Industry Rd,Marstons Mills,MA 02648
Date of Inspection: 02/20/05
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: 03/08/05
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 is no evidence of failure criteria. System consists of 1500
gallon tank with distribution box and 1000 gallon precast leaching pit.
****This report only describes conditions at the time of inspection and under the conditions of use at4hat
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05 ,
SOIL ABSORPTION SYSTEM(SAS): x . (locate on site plan,excavation not required)
If SAS not located explain why:
l
Type
X leaching pits,number: 1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): 1000 gallon precast leaching pit with cover to grade. Top of pit was down approximately 38".
CESSPOOLS:_NA (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: NA (locate on site plan)
Materials of construction.-
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg B
Owner:Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
TIGHT or HOLDING TANK: NA (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:working level
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.): There are no signs of solids carryover.Distribution box was at working level at
time of inspection.
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.):
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _ other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK x (locate on site plan)
Depth below grade: covers are to grade
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: 10.5' x 6' x 5'
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 35"
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. Structural integrity is
fine. Liquid levels in relation to tees are fine. There is no evidence of leakage. Covers are to grade.
GREASE TRAP: NA(locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3040 Falmouth Road, Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/30/05
FLOW CONDITIONS
RESIDENTIAL I
Number of bedrooms(design): 4 Number of bedrooms(actual) : 4 '
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):440
Number of current residents: 5
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no):no[if yes separate inspection required]
Laundry system inspected(yes or no):no ,
Seasonal use: (yes or no):no
Water meter readings, if available(last 2 years usage(gpd)):.
Sump pump(yes or no):no
Last date of occupancy:current
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):T
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 pumping schedule
Was system pumped as part of the inspection(yes or no):no ,
If yes,volume pumped:,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:Installed 1995. by
Bortollotti
Were sewage odors detected when arriving at the site(yes or no): no
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:3040 Falmouth Road,Osterville Pines,Bldg B
Owner:Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
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 ere 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.
x _ 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 4 of 11 i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION(continued)
Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
x Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
no (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply'-
_ _ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 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.
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION(continued)
Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05 i
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 CN IR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 2 of 11
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer 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:
. k
i
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3040 Falmouth Road,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/23/05
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
A a
0
3 Li
a 3 7`6
Page l l of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3640 Falmouth Road,Osterville Pines,Bldg B
Owner: Osterville Pines Condominium Trust
Date of Inspection: 02/20/05
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 22 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:
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)
_x Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Obtained from USGS maps.
I - - -- - --- - - -T-
___�_ _ CO
t - ,
a
d
1�, N
COMMONWEALTH OF MASSACHUSETTS '
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF.ENVIRONMENTAL PROTECTION
t
1.y Sim�`• i
TITLE. 5
OFFICIAL INSPECTION:.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM'
PART A
CERTIFICATION
Property Address: '
Ao,.�o. �
Owner's.Name: f n� i
Owner's Address: U r
Date of Inspection: ;Z� P/ri� '���, (.J 2
Name of Inspect or: p}ease print
EPT
r ' 1 3 2002
Company.Names > � i TOWN OF BARNSTABLE
Mailing Address: < •/� r HEALTH LPT
Telephone Number: 0fiLe —2 w Q
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address-and that the information mportted
below is true;.accurate and.complete.as of the time of the inspection. The inspection was performed based can 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 15.00.0). The system:
JPasses
Conditionally Passes
N eds Further Evaluation by the Local Approving.Authority.
77 F ils
Inspector's Sign ature: Date:
The system inspector shall submit a copy of this inspection report to the.Approving Authority.(Board of Healih or
DEP)within 30 days.of completing this inspection..If the system is a shared system or has a design flow of 10,000
Cr
gpd or greater,the inspector and,the system owner shall submit the report to.the appropriate regional office ofthe
DEP.The original should be sent to the system owner and copies sent.to the buyer, if applicable, and the ajproving
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.
Title 5 Inspection Form 6/15/2000 pacre I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART A
CERTIFICATION (continued)"
Property Address
Owner:
Date of Inspection: / 0
Inspection Summary:. Check A,B;C,D or E/ALWAYS complete all of SectionD
/ A. ystem-Passes-:
I have not,found anydriformation which indicates that any of the failure criteria,described in 3.10 CMR
15.303-or in 310 CMR 15.304 exist:Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board"of Health,will.pass.
Answer yes,_no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a.complying septic tank as'approved by th-Board of Health.
*A metal septic tank will.:pass"inspection.ifit is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 vears old is available.
ND explain:
Observation of sewage backup or-break-out or high'static-water"leve'1`iuthe,distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will-pass.inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than'4°times a year due to broken or obstructed pipe(s).The-system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s) are replaced
obstruction-is removed
ND explain:
2
Page 3 of I'1.
OFFICIAL INSPECTION FORM_--NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
-Property Address:
i
Owner: n �Z r��$, W)&4 - T
Date of Inspection: " Ct.
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(i)(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 environm.ent:.
_ The system has a septic.tank and's.oil 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 aseptic tank and SAS and the SAS is within a Zone 1 of a.public water supply. J
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
9
_ 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. r,
**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 freefrom pollution from that facility and
the presence of ammonia nitroaer-.and nitrite nitrogen is.-
to-or.less than5 ppm;provided that no other_
failure criteria are triggered.A,copy of the analysis:must be attached to this form. -
3. Other.:
E
Page 4 of 1 l
OFFICIAL INSPECTI.ON.FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DIS
POSAL SYSTEM INSPECTION FO
RM
PART A
CERTIFICATION(continued)
Property Address: �'` 14
'
Owner.
Date of Inspecfion: '—" 2/! g C30c
g� 1J.P_
D.. System Failure Criteria applicable,to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes, N.of
lA ackup of.sewage into�facility or-system component due fo overloaded'.or'clo�Qed SAS or cesspool
Discharge or ponding of effluentto 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 cloQaed SAS or
cesspool
_ iquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
equired.pumping more than 4 tunes 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 around water elevation.
j .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 5..0 feet of a private water supply well.
— Any portion of a cesspool or.privy is less than 100 feet but.greaterthan 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 formal
(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,the the system fails.The system owner should contact the Board of
'Health to determine what will be necessary to correct the failure.
E. Large Svstems:
To be considered a large:system the system must serve a facility with a'desien 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 i within g
— s rthin 400 feet of surface drinking water supply
— b PP Y
the system is within 200 feet of a tributaryto a surface:drinking-water supply
� P Y
P
— — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped
Zone
o 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.
4
Page 5 of 1.1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`F.ORM
PART B
CHECKLIST
PropertyAddress:
�
Owner: I' c G _ x 'i
Date of Inspection:
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 3
e- ere.any of the system components pumped out in the previous two weeks
_ Has the system received normal flows in the previous two week period
Nave 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,tiack 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.?
Pfacility ( p )P the propAr w Was.the facrli -owner and occupants different from owner :provided with- on -�.:-
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
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 1.5.302(3)(b)]
Page 6 of I 1
OFFICIAL-INSPECTION-FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART C . -
SYSTEM INFORMATION,
Property Address: fig `
�n
;Vq, A JA
Owner: Li _ <1
Date of Inspection: r G
LOW CONDITIONS
RESIDENTIALl� C/ LPL fiC, C i�
Number of bedroo d ms(; esi,n).T Number of bedrooms(actual).
DESIGNflow based on`3l0 CvR lS._03 (for example": 11'0b d x#of iedro om,s
)
-Number of current residents:..12
Does < .
residence.have.- garbage grinder(yes.or no)..
Is laundry on a separate sewage'system'(yeor nod;, �-.[if yes separate inspection required] \
Laundry system inspected(yes or no) .
Seasonal use: .'es or no: �
Water meter Teadings, if.ava�lable(last 2 years usage (gPd)):
Sump pump(Yes or
Last date of occupancy: • , �. �C v.� ��0
COMMERCIAL/INDUSTRIA:
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:. .
Was systern.pumped as pan ofthe i spection.(yes:or n _
If yes,volume pumped: _ gallons--How was,quantity pumped determined?:
Reason'for_pumping:
TYP F SYSTEM
eptic 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:ofthe DEP,approval
_.Other{describe):
(--Approximate age of all compo ents,date inst Iled(if known)and source of information:
n -
Were-sewage odors•detected when arriving.at the site(yes or no): —�
'6
page 7 of I I
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: 4 20,Z :&i
BUILDING SEWER(locate on site.plan�s/'�
Depth below grade:
Materials of.construction:_cast iron _40 PVC other(explain):
Distance from private water.supply well or..suction liner _
Comments(on condition of joints,venting, evidence of leakage,-etc) r.'" � ."
.SEPTIC TANK:Z(locate on site plan)
Depth below trade: &1 la'
Material of construction:,��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)
s/
Dimensions:/�• .d`�o �:
Sludge depth: & ''—1
Distance from top of sludge o bottom of outlet tee or baffle: d
Scum thickness: 1i'�"
Distance from top of scum to top of outlet tee or baffle: �.
Distance from bottom of scum to bottom of outlet ee.or baffl .
How were dimensions determined: ?.C, s
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural'integrity,,liquid levels
as related to outlet invert,Qvidence of leakage,etc.): -
.
lae
GREASE TRAP/1&4ocate on:site plan) Y
r
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain): ry
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,Iiquid levels
as related to outlet invert,evidence of leakage;etc.):
Paae'8 of 11 -
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORM_ArTION(continued)
Property Address Vv Aq� .r - )Powr-
Date of Inspections
T.IOHT 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: crallons
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:- (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
ahage into or gut of box4tc.):
PUMP CHAMBEIR: locate on site plan)
Pumps in'working order.(yes or no):
® ,
Alarms in working,order(yes orno):.
Comments (note condition of pump chamber,condition of pumps and appurtenances,-etc.):
8
Pase 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.;.;
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. C
SYSTEM INFORMATION(continued)
Property Addres21
�
.4 x L
Owner: . 'r '1✓�' Or�
Date of Inspection: ` ..9`
SOIL ABSORPTION SYSTEM (SAS):_4__A(locate on site plan,excavation not required)
If SAS not located explain why:
Type
� eachinc,pits,number:f
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, dam soil, condition of vegetation.
tc.):
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: m .
4
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.):
PRIIVY� (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.):
t.,
9
1
Pacye 10 of l l
OFFICIAL INSPECTION FORM-,NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
b�
Property Addre
Owner: �. A
Date of Inspection: t7/,=)00,a
SKETC14 OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system.including ties to at least two permanent ref rence landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
It �<
_ 10
Paae 11.of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued.)
Property Address:(' .,f�i" � � r + v y
c
Owner.
Date of Inspection: ao /' ✓ J
SITE EXAM
Slope
Surface water
Check.cellar.
Shallow wells
Estimated depth to around water ?r�`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:.
Observed site(abutting property/observation hole within 130 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:
il
Gcz_ion,:
M - ------------
r
R ,ddr=_ 'rsE rj!f/
;;es:
STEP } Measure deptrh to'w2La Dl /
oneorest i'!TC ...........•-- ........._........__ ..._ .. ............. Date
monzn/daYiY'�r
_ STEP
2 _ 1 .I'— using Water-l_ veI Ranee.7one
and rode- Weiil Ma locate
s.L= and C te'rt%1fnB: �. .
^ Approoriate-index, well---
US 1/Vet2r_I9V2I rance�.zon_'_.:..--.......................... �_� .
Jsina n-on dy re.port 'Cur.,ant
Water Resources-CondIL
'ior!s"
dB�ef,Tl.!i,e current O@Ci it ,G �•7
l
Wafer IeVe("TGr Inde>C'W IL_..._ . ._.........
•.....__ �iontn/Yes" � 1
i b
U5lnQ'JcD'I?Gi:U�at....�=i�V
or%nder,.W Vl I (S� �p 2^), cU-r rlt depth i
i
LC wa_=_r iev=1 or-inc a well. 'S!=P 3. ( • a
i ),
'and water-ls el zone.(STEP'25) "
detern-iine Wa _r e
S! _P: o. _stinate deo- -
_n �o nigh,water
oy subtracting the Water {.
level adjesment:(ST=P L).
ir.0M =cured dc�t- to w.;er.
level st,:_e 1S!_� ,Z
X.[11D i_oon ;ol:,r!. '
W_::. -_.
L� ��
COMMONWEALTH
EALTH OF-MASSACHUSETTS.
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _
DEPARTMENT:OF_ENVIRON.MENTAL PROTECT N
ONE WINTER STREET, BOSTON, MA 02108 617-292.5500
�41LL'IAM F.WELD
69vemor �RUDY COXE
ARGEO PAUL CELLUCCI joy��F9g9b 1 98 Secrettan
Lt.Governor TyoF ITAI�'�A'VID B.STRUHS
SYSTEM I
SUBSURFACE SEWAGE.DISPOSAL NSPECTION bu FORM COmmis ioncr
r PART A
CERTIFICATION c°' T
Property Address: UAJiT i3.3
Date.of Inspection; dS'�ty Address of Owner: B�ltkyc' Y c-
p S`Z5/�t3 (If different) 'i�.e,�, _
Name of Inspector: �'�•-� ��`�
t am a DE P approved system inspector pursuant to Section 15,340,of Title 5 (310 CM 15.000) �� � ��
Company Name: c S
Mailing Address:
Telephone,Number. ��� "� '��� /(noS•
L..
CERTIFICATION STATEMENT
I certify that I have personally.inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection, The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
-;k Passes:
_ Coriditionally Passes. _
Needs Further Evaluation.By`the Local°Approving Authority
Fails ...' _ .
Inspector's Signature: `
Date:,
The System Inspector shall submit a copy of this inspection report to the"Approving Authority within'thirty
inspection. If the system is a shared system or has a design flow Of 10,000 or reater h • m' d t days of completing this
the report to the appropriate regional office gPd 8 , the inspector and the system ownershall g of the Department of Environmental Protection. The original should be sent to the system uowner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, or D:
A] SYSTEM PASSES:
A— I have not found any information which indicates that the system viol
Any failure criteria not evaluated are indicated below. y ales any of the failure criteria as defined in 310 CMR 15.303.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. Th
completion of the replacement or repair, as approved by the Board of Health, will pass, a system, upon
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If"not determined", explain wh not.
The septic tank is metal; unless the owner or operator has provided the system ins y
Compliance,(attached).;indicating that the tank was installed within twenty(20) years priortohthe date of he inspection a Certificate ; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health,
(revised 04/25/97) `
Pawls i of 10
DEP on the World Wide Web: http:/twww.magnet.state.ma.uss/dep
Cj Pnnlr:y nn Ra
�YCI�d Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
:'PART A
CERTIFICATION (continued)
Property Address �.._ r�r %z. - � , ••3 �
Owner:
Date of Inspection: c-
01,SYSTEM CONDITIONALLY PASSES (continued)
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 unevsn:distribution box. The system will pass inspection if (with approval of the
Board,of Health). Describe observations:'
broken pipe(s) are replaced:
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
• `� broken pipe(s) are replaced
obstruction is removed
C) F�gURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: !
�r Conditions ons exist
st which-require
further evaluatio
n by the Board.of Health in order to determine if the system is failing to protect the
public health, safety and the environment. ,
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
_. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_. The system has a septic tank and soil•absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97)
Pago 2 of 10
V
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION (continued)
Property Address
Owner:
Date
of Inspection.C
D) S�STEM FAILS: V ;
You must indicate ei;•,er "Yes" or "No" as to each of the following:
I have determined that the system violates one'or more,of the following failure criteria as defined.in 310 CM
for this determination is identified below, The Board of Health should be contacted to determine what will be necessaryt
R 15.303. The bans
the failure. �I
o correct
Yes No
— Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
— — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 112 day flow.
Required oumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
— Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
PP Y ry
Any portion of;a cesspool or privy PP y p vy 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 co
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. py of well water analysis for
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
4The following criteria apply to large systems in addition to the criteria above:
/f The system serves a facility with a design flow of•.10,000
System) an 'the syte
public health and safety and the•environ'ment because one or more of thecarge following condtions exist: is a significant threat to
Yes No
— the system is within 400 feet of a surface drinking water supply
— the system is within 200 feet of a tributary to a surface drinking water supply
— the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97)
Pago 3 of 10
. . A.
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:nl;�..j �,:.'yk�\,i..:�':_ i.c.�E•' � ,
Owner. �'V,
Date of Inspection:cff Z /
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
— None of the system components have been pumped for at least 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.
--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 the site.
— The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance o
Sub-Surface Disposal System.
— 5 Existing information. Ex. Plan at B.O.H.
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)]
(revised 04/75/97)
Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address':-z
Owner: �,,z ,
Date of Inspection:-- f(
RESIDENTIAL- FLOW CONDITIONS
Design flow: 1h
f b �•P d./bedroom for S.A.S.
Number of
Number of current residents:
Garbage grinder (yes or no):-:�Yf1
Laundry connected to system (yes or no):QC'-(�
Seasonal use (yes or no):_ UU—
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):�1 4A----------------
Last date'of occ'upan t. .w _ . - • t . , „
COMMERCIAUINDUSTRIAL:
Type of establishment: w/A
Design flow:—gallons/day
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:
OTHER: (Describe)
Last date of
. GENERAL INFORMATION !
PUMPING RECORDS and source of information: ll
System pumped as f inspection: (yes or no) LL , Q-C'-p-j%
pan o C If yes, volume pumped: 3i
Reason for Pumping: gallons
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)
I/A Technology etc.Other Copy of up to date contract?
APPROXIMATE AGE of all components, date installed (if known) and source of information: °
Sewage odors detected when arriving at the site: (yes or no)
(r—iled 04/25/97)
0&90 5 of 10
1
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:a
Owner:
Date of Inspection:
BULCDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, v evidence of le
akage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader
material of construction: Lconcrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: �f>)
Sludge depth:_ L t
Distance from top of sludge to bottom of outlet tee or baffle:Z.��w
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:
How dimensions were determined:--. .;4,\�Q ti►)
^CJL�^L.r.a.�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integnn,, evidence of leakage, etc.)
(� C-
1
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass ,_Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(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.)
(revi..d o1/2s/97)
Page 6 01 10
u
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:7k' 3
p
Date of Inspection:c?
TIGHT OR HOLDING TANK: t ff (Tank must be
(locate on site plan) pumped
prior to, or at time, of inspection)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity:_ gallons
Design flow: _ a .. .
gallons/day
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_ Cam•
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, �c.) i
i •
PUMP CHAMBER:)dJA.
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(-i..d 04/25/97)
Page 7 o1 10
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addressi-3-_3_ t��� �
Owner: , \ '
Date of Inspection: Ck�ZSACve
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by no
n=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:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
\
CESSPOOLS: P3
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of,vegetatiori, etc.)
PRIVY: dA
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97)
Page 0 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART t
SYSTEM INFORMATION (continued)
Property Address55—"-1,,,
Owner: _��g'�_
x
Date of Inspection:
Ci l 2Tf S.8
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
IY.�i�►'O'P��L�LI �jt.� ,
A
! 11
35
z si
3l
�-V _ 39`b
Sv
(rovined 04/25/97) _ -
Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION (continued)
Property Address.—
Owner:
Date of Inspection: 'y tt ` <'-f/z v
Depth to Groundwater LJ rFeet
Please indicate all the methods used to determine High Groundwater Elevation:
eLObtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
✓' Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
(revised 04/25/97) Page 10 of 10 '