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HomeMy WebLinkAbout0716 MAIN STREET (OST.) - Health (3) 716. BLgiA?Main Street (Ost.) Osterville P UPC 12134 • • No.215.3LGN 'p;97S7•CON6���o- HASTING4,EAR / �i �'�rn ;r � t 7� 9 ; � �� �°� ,� �� Commonwealth of Massachusetts 00 * Title 5 Official Inspection Form _ I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �9 p Y rY 716 Main Street;{Bldg. A) cpa- u Property Address =1 Cotacheset:Village Association f Owner Owner's Name I information is - required for every Osterville MA 02655 8=31-20 7 page. City/Town State Zip Code Date of Inspection t-� 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. r-I _ Important:When filling out forms A. General Information on the computer, -1 use only the tab 1. Inspector: key to move your cursor-do not Michael Sears use the return Name of Inspector key. Robert B Our Co INC. rab Company Name 363 Whites Path Company Address rein South Yarmouth MA 02664 City/Town State Zip Code 508-477-8877 S114430 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: ����►uununp,,,� OF nfASS��p4 ® Passes ElConditionally Passes ails q°y', MICHAEL '.N ❑ Needs Further Evaluation by the Local Approving Authority o SEARS No.SI14430 0 .FR.T If 8-31-20 ''��i��uNinNms`g1����```` Inspector's Sig re 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 should be sent to the system owner,and copies sent to the buyer,,if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use . at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 . Title 5 Official Inspection Form:Subsurface Sewage_Disposal System•Page'1 of 17 L Commonwealth of Massachusetts I1 Title 5. Official Inspection Form �i� Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association - Owner Owner's Name information is required for every Cisterville MA 02655 8-31-20 page. City/Town State Zip Code Date of Inspection B. Certification (cont:) Inspection Summary: Check A,B,C,D orE%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 31.0 CMR 15.304-exist. Any failure criteria not evaluated.are` indicated below. - Comments; The system is a-5000 Gal. H-20 Tank D Box and three pit's. F B) y y System Conditional) 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 thejank is less than 20 years.old is available.. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts �v Title 5 Official Inspection Form I. I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments !% 716 Main Street (Bldg. A) V� Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655 8-31-20 required for every page. Citylrown State Zip Code .Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational: System will pass with Board.of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): F ❑ :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 passlinspection if(with approval°of the Board of-Health): ❑ broken,pipe(s)are replaced. 0 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form e Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655 8-31720 required for every page. City/Town State Zip Code Date of Inspection B. Certification .(cont.) 2. System will fail unless the Board'of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic 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 aseptic tank and SAS,and the SAS is within 50 feet of a private water supply well. El 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: r System Failure Criteria Applicable to All S D) Syst pp stems:y You must indicate "Yes" or"No"to each of the following for all inspections::, Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool I El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ,® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc•rev.6116 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Offi-cia" Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg. A) u Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655" 8-31-20 required.for every _ page. City/Town State Zip Code Date of Inspection B. Certification (COnt.)' Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Z Any portion of the SAS, cesspool or privy is below high ground water`elevation. El ® 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 waterquality 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 Elthe system is located'ih a nitrogen sensitive area (Interim Wellhead Protection 11 Area—IWPA)or a mapped Zone 11 of a public water supply well, If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M � 716 Main Street(Bldg. A) V� Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 8-31-20 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 r n f he system components pumped out in the previous two weeks? ❑ ® Weea any t y p p p ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water beewintroduced to the system recently or as part of this inspection? ® El -available 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 El 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. El ® 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): 18 Number of bedrooms (actual): 18 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2970 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts �v Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 - 8-31-20 page. City/Town State Zip Code Date of Inspection D. System Information F Description: The system is a 5000 Gal. H-20 Precast tank D Box and 3 pit's. - Number of:current residents: NA Does residence have a garbage grinder? ❑'.Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes 2 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)):. NA Detail: Sump pump? ❑ Yes Z No Last date of occupancy: present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ,❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form I;, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 716 Main Street(Bldg.A) u Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 8-31-20 page. City/Town State Zip Code Date of Inspection D. System Information(cunt:) Last date of occupancy/use: i Date Other(describe below): General Information Pumping Records: November 2016 Source of information: Was system pumped as part of the inspection? ❑ Yes ® ` No If yes, volume pumped: gallons . How was quantity pumped determined? Reason for pumping: Type of Systema ® Septic tank, distribution box,•soil absorption system El Single cesspool' ❑ x Overflow cesspool ' ❑ Privy Shared system (yes or no) (if yes, attach previous inspection records; if any)' ❑ In 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 0 Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rec.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page El of 17 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 8-31-20 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; 1985 Permit#85-268. Were sewage odors'detected when arriving at the site? ❑ Yes ® No . Building Sewer(locate on site plan): 26" Depth below grade: Meet Material of construction: ❑ cast iron ' ®40 PVC ❑ otherJexplain): Distance from private water supply well or suction line: i feet Comments (on,condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC. e - . Septic Tank(locate on site plan): 20" Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age:, years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5000 Gal. Precast . 2„ " Sludge depth: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r c Commonwealth of Massachusetts �v Title 5 .Official Inspection Form yI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset'Village Association Owner Owner's Name information is required for every Osterville MA : 02655 8-31-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(coat Distance from top of sludge to bottom of outlet tee or baffle 36" 2„ Scum thickness Distance from top of scum to top of outlet tee or. baffle 8" Distance from bottom of scum to bottom-of outlet tee or baffle 14" How were dimensions determined? Tape,Plan,Asbuilt Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural:integrity, liquid levels as related to outlet invert, evidence'of leakage, etc.): Tank at working level Win and outlet Tee's in place: Both covers steel at grade. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of.Massachusetts Title 5 Official. Inspection Form 5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg. A) V� Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 8-31-20 i Date of Inspection State 2 Code City/Town/Town P P a e. Y p9 D. System Information cont. F 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 HoldingTank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i Commonwealth of Massachusetts �u Title 5 Official Inspection Form r. �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 8-31-20 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.): D Box is 3' below grade w/three lines out. With steel cover at grade. 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form r 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�uJ 716 Main Street(Bldg. A) Property Address Cotacheset Village Association - Owner Owner's Name information is required for every Osterville = MA 02655 8-31-20 page. City/Town State Zip.Code Date of Inspection D. System Information (cont.) Type: leachingits number: : p 3 El 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.): Leaching is three 1000 Gal: pre cast pits..W/2' shim and 4'stone per plan all pits have steel cover's at grade to 2 No sign of over loading or solid carry over. 4"water in pit's. 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.doc•rev.6116 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17" Commonwealth of Massachusetts - �� Title 5 .Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .......... 716 Main Street(Bldg. A) i Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville F MA 02655 8-31-20: page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition,of soil,;signs,of hydraulic failure, level of ponding,condition of vegetation, - etc.): y r Privy(locate on site plan): - Materials of construction: q Dimensions - r Depth of solids Comments (note condition of soil, signs.of„hydraulicfailure, level of ponding, condition of vegetation, etc.): _ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 _ A Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg. A)_ Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osteryille MA 02655 ` 8-31-20 page. City/Town State Zip Code- Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within-100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ =hand-sketch in the area below ® drawing attached separately t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 c� Commonwealths of Massachusetts Title 5 Official Inspection Form +_ �I Subsurface Sewage Disposal System Form-Not for-Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA '02655 8-31-20 page. City/Town State Zip Code Date'of Inspection D. System Information (cont.) Site Exam: ® Check Slope . ® Surface water ® Check cellar Z Shallow wells 12+ Estimated depth to high ground water: feet Please indicate all methods used.to determine the high ground water elevation: ® Obtained from system design plans on record If checked,'date of design plan reviewed: 1985 'Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local-Board of Health -explain: ❑ Checked with local excavators; installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plain Site high from road. Before filing this Inspection'Report; please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts t r� Title 5 Official Inspection ,Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s ' 716 Main Street(Bldg. A)' Property Address Cotacheset Village Association Owner Owner's Name information is Osteryille MA 02655 8-31-20 required for every page. Cityfrown State` Zip-Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C; D, or E checked 5 Z jInspection Summary.D (System°Failure Criteria Applicableto All Systems),completed Z System information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System..either drawn on page 15 or attached.in separate.file t l5ins.doc-rev-6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Aug 18 20,01:38p Capewide Enterprises 5084774977 p.13 eb 01 18.00:46a Capew cis Entarprises 508-477.4977 p.2 L 0 C A T !17;r1 �,' S f VAC $ 'P f_.A.l�l;r No. yu-•=r INs7ALLER':S M A ME 4 A.DDRE55 QCt38�" rL.G� i 10 UILDE R. op cowM-ja 1 0 A 7 E P E R m 17 9 5 S E D "•—-`-- DA7 E C0MPLIAaCE 15S.U [a �� TtZ�aT .NK-i 11 'y5 z s _ t�V L�l�� dEa�troai�y�t� gE abed xed dH owe 9oz 66 �. i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street(Bldg. A) 4� Property Address ca Cotacheset Village Association U Owner Owner's Name intonation is required for every Ostervllle MA 02655 2-5-18 -j ... page. City/Town State Zip Code Date of Inspection k+e1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information S/# /a 133--, onng out the computer, ���\`,``�`��.OFr rms �sSq use only the tab 1. Inspector: '2 Y our a � key to move C:- cursor-do not James D.Sears = .LAMES use the return ke . Name of Inspector :* ti Y Capewide Enterprises •-�F rGo. Company Name s�o lF 5. p Cj 153 CommercVQial Street �'��rn,nnmr„ovo\\ Company Address Mashpee MA 02649 . CitylTown State Zip Code 508-477-8877 S 1623 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 2-9-18 ,Zispector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 role 5 Official Inspe0or Form:Subsurface Sewage Disposal System-Page 1 of 17 0Z a5ed xed dH WOZ 202 1.6 gaad r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name requir required is Osterville MA 02655 2-5-18 required for every page. Cityr'rown State Zip Code Date of Inspection B. Certification (cunt.) 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: The system is a 5000 Gal. H-20 Tank D Box and three pit's. 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.doe-rev.WIS Titte 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 6Z a5ed xeJ dH WOZ 81.0Z 66 qaJ f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner owner's Name information is required for every Ostervllle MA 02655 2-5-18 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 t5insAW•rev.6l16 Title 5 Dfrdal Inspection Form:Subswfeoe Sewage Disposal Syelem-Page 3 of 17 ZZ a5ed xed dH WOZ 9 60Z 1.1. qaH i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 716 Main Street A (Bldg. ) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 page. City/Town State Zip Code Date of Inspection B. Certification (cant.) 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 is less than 6" below invert or available volume is less than day flow f t5ins.doc-rev.6116 Title 5 official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 17 EZ a5ed xed dH 9t,:OZ 21,0Z 61. 9aJ c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osteryille MA 02655 2-5-18 page. Cffy/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system Is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 1 .y 5 304. The system owner should contact the appropriate regional office of the Department. 15ins.doc•rev.6116 Title 5 Oftel Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 bZ a5ed xeJ dH Lb:OZ 860Z 66 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,may 716 Main Street (Bldg A) Property Address Cotacheset Village Association -- Owner Owner's Name information is Osterville MA 02655 2-5-18 required for every pates City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out In the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction; dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 18 Number of bedrooms(actual): 1s DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 2970 t5ins.doc-rev.6!16 Title 5 Official Inspection Forth:Subsurface Sewaae Disposal System-Page 6 of V 5Z abed xed dH Lt:OZ 9 60Z 61• gad i Commonwealth of Massachusetts Title 5 Official Inspection Form RSubsurface Sewage Disposal System Form- Not for Voluntary Assessments M S' 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 5000 Gal. H-20 Precast tank D Box and 3 pits. Number of current residents. NA 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)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commemialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): canons per day(9pd) 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: Mns.doc-rev.6116 Title 5 Offidal Inspecticn Form Subsurface Sewage Disposal System-Page 7 of 17 gZ a5ed xed dH 8V:02 8 tOZ 6 6 gad i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner, Owners Name for every iequir tion is requiretl Osterville MA 02655 2-5-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5lns.doc•rev.6116 Tille 5 official Inspection Form:Su"ace Sewage Disposal System Paige 6 of 17 �Z abed xe:1 dH 8V:0Z 91,0Z 66 qad i Commonwealth of Massachusetts 5 le Tit Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments RV716 Main Street(Bldg. A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 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: 1985 Permit#85 -268. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26" feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC. Septic Tank(locate on site plan): Depth below grade: 20" feet Material of construction: " ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5000 Gal. Precast Sludge depth: 211 t5ins.doc•rev.ISMS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 8Z a5ed xe: dH 8b:OZ 260Z 66 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street (Bldg A) Property Address Cotacheset Village Association Owner Owners Name information is required for every Osterville MA 02655 2-5-18 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt:) Distance from top of sludge to bottom of outlet tee or baffle 3611 Scum thickness 2" 8 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? Tape,Plan,Asbuilt Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level w/in and outlet Tee's inplace, Both covers steel at grade. No sign of leakage or over loading. 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 15ins.doc•rev.611E Title 5 OffCel InspeGlon Form:Subsurface Sewage Disposal System•Page 10 of 17 6Z a5ed xed dH WOE 2 0Z 66 qad Commonwealth of Massachusetts 10 Title 5 Official Inspection Form �{ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 716 Main Street(Bldg A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 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 15ins.doc•rev.1116 Title 5 Official hlspecuon form:Subsurface Sewage Disposal System•Page 11 of V 0£ a5ed xed dH 6b:OZ 860Z 66 Q�d Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments F 716 Main Street(Bldg A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osteryille MA 02655 2-5-1 S pegs 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.): D Box is 3' below grade wlthree lines out.With steel cover at grade. 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.Coc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pege 12 of 17 I.£ a5ed xe:1 dH WOZ 21.0Z 66 qad i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form• Not for Voluntary Assessments ° 716 Main Street (Bldg A) Property Address Cotacheset Village Association Owner Owner's Name information Is required for every Osterville MA 02655 2-5-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ Teaching 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.): Leaching is three 1000 Gal. pre cast pits.Wl2' shim and 4'stone per plan all pits have steel cover's at grade to 2" No sign of over loading or solid carry over.4"water in pies. 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 tfilns.doc•rev.6116 Tide 6 Ofticiel Inspeclbi Form:Stbsurfaee Sewage Disposal System•Page 13 of 17 E£ a5ed YPJ dH WOE 860E 66 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg A) Property Address Cotacheset Village Association Owne; Owner's Name information is required for every Osterville MA 02655 2-5-18 page. CityfTown State Zip Code Date of tnspection 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.): 15ins.doc-rev.6116 Tole 5 Offidel Inspectior Form:Subsurface Sewage Disposal System•Pepe 14 of 17 ££ a5ed xed dH 05:OZ 860Z 1, 9ad Commonwealth of Massachusetts vw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 716 Main Street(Bldg A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-1 B page. CityRown State Zip Code Date of Inspedion 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 t5ins.doc•rev.WA Title 5 Official Inspection=wm:Subsurface$",age Disposal System•Page 15 of 17 b£ a5ed xed dH 09:0Z 860Z 66 qad I Feb 01 18,09:45a Capewide Enterprises 508-477-4977 p.2 ti� I LZFifr� f}'t CL ft�S£'� - - 5 EW'A C E PE RAfIT P0. � iILACE ~ �,. �— INSTALLER'S NAME to ADDRES5 113IJILDE R Up nSiWNII :-Qi A, S- 7 t UP C_ _ tIATE PIRRII ' ISSUED DATE C0VPLIAPICE ISSUE1) a s d V �LD/ d£0't0 Zl L L MEIN 5£ a5ed xed dH OS:OZ 86N 66 9ad Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg. A) " Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655 2-5-18 required for every City/Town page State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells O Estimated depth to high ground water: 12'+ 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: 1985 Date ❑ Observed site (abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: T H on Design plan. Site high from road. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ms.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 9£ abed xed dH 09:OZ 8 60Z I•I, gad I . r I C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 716 Main Street(Bldg A) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 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 Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L£ a5ed xed dH 1•9:0E 81.02 Li, qad 4t -A- / 6 37 —(36 L ` Commonwealth of Massachusetts Ulm A-3 �^ Title 5 Official Insp ectioA Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 M 6 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When fillip out forms A. Genera! Information 4 5 / ��au►►ununu� on the computer, t ,O g(� iP ```\��O��N OF lygss4,,��. use only the tab 1. Inspector: J.- z4 •9°tip key to move your � o N cursor-do not JAMES use the return James D. Sears =C-3. oCAD S _ key. Name of Inspector • o Capewide Enterprises, LLC ��••.�' ���:�� �11 Company Name � lF SSPEG 153 Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 4-13-15 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority.(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. .oGY� •�,J' t5ins•11/10 Title 5 Official Inspection Form:Su Sewage Disposal ystem•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 5000 Gal. H-20 Tank D Box and three pits. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within` 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water. supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: - This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 mili is less than 6" below invert or available volume is less than Y2 day flow P177.�s t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "r 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Cl ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY M �y 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-1345 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 18 Number of bedrooms(actual): 18 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 2970 t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 5000 Gal H 20 Pre cast tank D Box and 3 pits Number of current residents: NA 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 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date Commercial/Industrial Flow Conditions: -Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No MIndustrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection D, System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 5/9-5/ 10-4/12 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Tide 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 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 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: 1985 Permit # 85-268 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): - Depth below grade: 26"feet Material of construction: ' ❑ cast iron .®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Piping is 4" pvc Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5000 Gal Pre Cast Sludge depth: 2" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 36" Distance from top of sludge to bottom of outlet tee or baffle f 1p Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape, Plan, Asbuilt Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level w/in and outlet Tee's inplace, Both covers steel at grade. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Citylrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 3' below grade w/three lines out. With steel cover at grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption.System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owners Name information is required for every Osterville MA 02655 4-13-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑' innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is Three 1000 Gal Pre Cast Pits, W/2'shim and 4' stone per plan all pits have steel covers at grade to 2" No sign of over loading or solid carry over 4"to 6"water in pit's. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jay 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M z 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Flame information is required for every Osterville MA 02655 4-13-15 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 7/6 7" 057- { � _ , S � ?3• Id ;J i" v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y�< 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NO Estimated depth t h 12'+igh ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: GW off Plan f ' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 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 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 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 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts .AgN W Title 5 Official Inspection For subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Wage at Cotacheset o+.nees r irrtasmaainn� requimd for emy t'?sterviile MA 02655 5-17-12 Me. cdymoum Stain zip Code Daft of Inspection Inspection results must be submitted on this form.Inspection forrns may not be attered in any way. Please see completeness checklist at the end of the form. A. General InformationVk OF As on me connmer, yn, the tab Inspector cr. ke�ybantaw yo'u _: DAMES cursor-do not James D. Sears e o use the turn _ SEARS m _ Name or(nspecW Capewide Enterprises, LLC Company Nanw 5 I N Sp ;`N"' 153 Commercial Sheet ,Nruuu1111100�� Company Address Mashpee MA 02649 CitylCown state 23o Cone 508-477-8877 S1623 fe�pt-tee N+ uoense N x„ber B. Certification t certify that I have personally inspecWd the sewage dis o a 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 maintenartce of on site swage disposal systems.i am a DEP approved system actor pursuant to Sort 15.340 of 71 to 5(310 CIVIR 15.M).The system: Passes ❑ Conditionally Passes ❑ Fad ❑ Needs Further Evaluation by the Local Approving Authority 5-17-12 s Signature pate 1 r ��' The system inspector shall submit a copy of this inspection report to the AppfW,h P.bii' (Board of Health or DEP)within 30 days of completing this inspection. If the system is'a�shared syster�'c3 has a design few of 94.000 gpd or greater,the inspector and the system ownerrshall subrrfit they, report to the appropriate regional office of the DEP, The original should be sent to the sy�ern o>aer and copies sent to the buyer, if applicable, and the approving authcNity. n 'This report only describes cond-rtions at the time of inspection and under the candilons,ikuse at that time.This inspection does not address how the system Will perfo"in the future under the same or different conditions of use. 12%w•tuna , TBts s astiar Fb=&triad&—w vap-w s—•raps 7 Of 1 v 71 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments 716 Main Street BLDG. A ✓ Property Address Villacre at Cotacheset c3Ma:er owner's tine irtfo:ps�iaat is . wed for every 0steiville MA 02655 5-17-12 page. Citylrom state ZFp code Date or Wspectim B. Cerfification (rent.) Inspection Summary:Check A,B,C,D or E I always complete all of Section D A) System Pages; 1 have not found any information which indicates that any of the failure criteria desc fled in 310 CMR 15,303 or in 310 CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Condh5onally Passes. ❑ One or more system components as described in the`Condiifonal 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, ICI, ND)for the following statements. If"not determined,"please expfain, The septic tank is metal and over 20 years old'or the septic tank(whether metal or rot)is strueWralty unsound,exhibits substantial iafiftration or exfiltration or Uink failure is imminent System vAff pass iris on 4 the emWinng tank m rusted with a cornp4wiq septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally tend, not leaking and if a Certificate of Compliance indicating drat the tank is less than 20 years old is available_ ❑ Y ❑ N ❑ ND(Explain betoui): rsers•nno Tme 5 01fi=trspD=n Fes;SOMAt3m SNOOD t]tPmW Sliftm-Pape 2 d 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessrnentz 716 tillain meet BLDG. A Property Address Village at Cotacheset owner Owner's Nar9e ifffbIrnaftla is reQuired for every Osterville MA 02655 5-17-12 lam• CWown star zip code Date of knpectim B. Certification (coat.) B) System Conditionally Passes(coat): (] Observation of sewage backup or break out or high static water Level in the distnbutiorr box-dine 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): ❑ obsbuebon is removed ❑ Y ❑ N [I ND(Expo belawy: ❑i distribution box is leveled or mplacedi ❑ Y ❑ N ❑ ND(Explain below): The system required pumping more than 4 times a year rue to broken or obstructer!pipe(s)_The system van pass inspectiom if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain betowy: ❑ obstruction is removed ❑ Y ❑ N ❑ ND(plain belay): C) Further Evaluation is Required by the Board of Health: ❑ Coriditions exist which require further a aktation by the Board of Huth in order to ale if the system is failing to protect public health, safety or the environment. I. System wilt pass unless Board of Health determines in acccoWance with 310 CMR 15.303(1)(b)that Ute system is not functioning in a mariner which Will Protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a wrface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh •tine tkls s Oar Form Sart�cs +D 9rs'�•r'apt..��. f Commonwealth of Massachusetts Title s Official Inspection Form SubsttrEace Sewage Disposal System Farm-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset own" t3ymer's Norm Osterviile MA 02655 5-17-12 reawed for emy page. Cityf town Mp code Date of frmpecwn. B. Cerulienbon (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 envinoMmmnk Q The system has a septic tank and sal absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. Q 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. Q 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 determ*m dttancm '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliiform 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.. Mer: D) System Failure Criteria Applicable to All Systems: You must indicate"Yea"or"He to each of the fig for ag marts:. Yes No Q ® Backup of storage into farmer or system con nponient due to overloaded or dogged SAS or cesspool Q ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Q ® Static liquid level in the distribution box above outlet invert due to an overloaded or cbMed SAS or cesspool Q ® Liquid depth in cesspool is less than G"below invert or available volume is less than %day flow •t fin Zme 5�tsyeeban 5amr 3esape o;�poset S •Pags4�t7 r - c Comrlrionwea[th of Massachusetts Witte 5 Official inspection Form Subswlace SewaW Disposal Systarn Form-)dot for Voluntary Assessments 716 Malin Sheet BLDG. A Property Address Village at Cotac et owner ors to hff0fMa*M is nxpked Ear every Osterville MA 02655 5-17-12 page. CWTO" state Zip code Date of hwpecson $. Cer ification (coat.) Yes No ❑ Required pumping more than 4 times in the fast year NOT due to clogged or obstruct pipe(s).Number of limes pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any-portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 ARy portion of a cesspool or privy is within a Zone 1 of a public welt, ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ IR Any portion of a cesspool or privy is Tess than 100 feet but greater than 50 feet from a private water supply well with no aeceptabie water quality analysis. Uhis system passes if the wail water analysis,perforrned at a DEP certified laboraory,for fecal conform bectwia indig,ates 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 cm tody must to atbw4md to#ft foam.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The systern fads.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 arrect the faWure, 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 drinidng 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—f"A)or a mapped Zone 11 of a public water supply welt If you have answered"yes"to any question in Section E the system is considered a slgnffkxmt threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant thread under Section E or tailed under SecWm D sly upgrade the system In accordance with 310 CMR 15.304.The system owner should contact the approprIM regional office of the Department t33ns•ifl1Q Tmc 5 CMda! Fad-UA)a xt=Sewage ptrwsa,'�r�v•Few 5 d 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Fornt-Not for Voluntary Assessments 715 Main Street BLDG. A Property Address Wage at Cotacheset Omer Oti MWS Dame � Ostervifle �kW for every MA 02655 5-17-12 page. Cftgrown state Tp Code Date of Inspection C. Checkftt Check if the following have been clone.You must indicate'yes"or°no°as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have laW w9umes of water been introduced to the system recant or as part of this inspection? ❑ Were as built pans of the system obtained and examined?(if they were not availatLe WW as WA) ® ❑ Was the facttRy or dwelling inspected for signs of sewage back up? ® ❑ Was the site irrspectet!for signs of break out!? ® ❑ Were of system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of ffi6 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 Absorptlon System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ 0 €ekwnined m tie field(if any of the failure criteria retated to Part C is at� approximation of distance is unacceptable)(310 CMR 13.302(5)1 D. System Information Maki!ential Flow Comore: Number of bedrooms(design): 18 Number of bedrooms(actual): 18 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 2WM arm-„cs� rma 5 OMCW FUM&=QU=seta Sys paw aart7 I - . Co mmonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 716 Main Street BLDG. A Pwp"Address Vifage at Cotacheset Oar Owners Nam requkedfo is Ostenriile MA 02655 5-17-12 required for every POW, Cityrrown State Zip Code Dee of i"pedion D. system information Description: The system is a 5000 Gal H 20 Pre cast tank D Box and 3 pits Number of current residents: NA Does residence have a garbage grinder? ❑ Yes to Is laundry on a separate sewage system?rd yes separate inspection required) ❑ Yes 0 NO Laundry system inspected? ❑ Yes ® W Seasonal use? ❑ Yes ® NO Water meter readings, if available(last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes 0 No East date of occupancy: Date Comrnercialfindeaddal Flow Condiflons: Type of Establishment: Design Row(erased on 310 CMR 15.203): Gauwmw day WO Basis of design flow(seatslpersonslsgA,etc.): Grease trap present? ❑ Yes ❑ NO Industrial waste holding tank present? ❑ Yes ❑ No Non—sanitary waste discharged to the True 5 system? ❑ Yes ❑ No Water meter readings,if available: t5tes•t tt`Q Fms 5�trnpectcn Fan:S.m�aface�dae S'r�Eom'P�7 d t7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street SLDG_ A Pr�rtY Address Vi!189e at Cotacheset Owner CMnees Mam hdomiation is flstervitie requked for C1wY stervil MA 02655 5-17-12 state ,dip Code Date of kmpertion D. SYStem Information (cunt.) Last date of occupancyluse: Date Other(describe betaw): Generai kdbrrnafion Pumping ReCorda; Source of information: 511 g-5110 Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: tan How was quantity pumped determined? Reason for pumping: Type Of systm: 0 Septic tank,distribution box.soil absorption system Q Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)fit yes.attach previous inspection records, if any) ❑ tnnovativelAttemative 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 11A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Troe s O�he�edipn fexere � 9rs�-�dd t7 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 5-17-12 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: 1985 Permit#85-268 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Piping is 4" pvc Septic Tank (locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 500C Gal Pre Cast Sludge depth: 2" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 CommonweaM of Massachusetts Title 5 Official Inspection Form U brsurface Sewage DEsposall System Form-Not for ValuntM Assessments 716 Main Street BLDG. A �party Address Village at Cotacheset tamer Owrfer's Narne lMamudim ss requ d for every Ostenn-He MA 02655 547-12 . City/'rom state Zip Cade Date of tropectkm D. System information (coat.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 2" Distance from top of smm to tap of outlet tee or baffle 8" Distance from tam of scum to bothorn of outlet tee or Waffle 14D Howl were dimensions determined? Tape,Man,Asbuitt Continents ton pumping recortarrw4aborts.inlet and outlet tee or baffie conditon, sutural int gnty, Liquid leveis as related to outtet invert, evidence of Leakage, etc.): Tank at working level w/in and outlet Tee's inplace, Batts covers steel at grade_ No sign of leakage or over taadino Grease Trap(locate on site plan): Depth below grade: kid Material of construction: fl concrete ❑metal []fiberglass Q polyethyleene ❑of w(e)plain): Dirnei'tsiorts: _ 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 lumping: l3e,s•t 1nQ Tab 5 05c1d k%Peb0e Force Db=M on sa mW DSPOSM Sligm•Pao Vat 17 commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Dlspasal System Form-Not for Voluntary Asses&rnents 716 Main Street BLM A Property Address Village at Cotachsset � Chun" Owner's Name Uftmnabw is Ostemilie MA 02655 5-17-12 requite for eV+e1y page. CWTown state Zip Code t}atf:of knpectim D. System Information (cost.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leafage,etc.): Tti M or t! MhV Tank.(tank must be pumped at time of Wopection)(locate on site lam): Depth below grade: Material of construction: C7 concrete ❑metal ❑fiberglass Q polyethylene 0 other(explain): Dir+�n;;rorls: Capacity: Design Flow: pRom Per dW Alarm present © Yes ❑ No Alarm levet: Alarm in marking order: 0 Yes [3 No Date of last pumping: Comments(cortdb)n of alarm and float switches,etc.): •Attach copy of current pumping contract{rewired}-is copy attached? 0 Yes 0 No fsios-t ttf 0 rft 5 of cW rwacbm Form SdAudm&90evapeDbowal •Page tt of V Commonwealth of Massachusetts Title 5 Official Inspection Fora I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 716 Main Street BLDG. A Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 5-17-12 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.): D Box is 3' below grade w/three lines out With street cover at grade Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form Sl bsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form UVSulmurfsce Sewage talsPosal System Farm-Not for Voluntary Assessments 716 Main Street BLDG. A V(liage at Cotacheset owner kdbrnavon is t�stervitle required for every AAA 02655 5-1 l-1.2 PP. cityfrawft state Zip Code F3a*of kepedim D. System information (cunt.) Type: ® l fig pits number: 3 ❑ teaching chambers number: Q leaching galleries number. Q leaching trenches number, length: -- ❑ leaching Melds number,drrtens>ans: ❑ averflow,cesspool number: D innovativefalternative system Typeiname of technology: Comments(nee coW tion of soil,signs of r"raefrc failure, Of pondmg,damp sail,condition of vegetaltn,etc.): Leaching is Three 1000 Gal Pre Cast Pb, W/2'shim and 4'stone per plan all pits have steel covers at grade to 2" No sign of over loading or solid carry over Cesspools(cesspool gust be pumped as part of inspection)(lode an site ptan): 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 Mow ® Yes ❑ No ISM-tIna Td*5 DffcW kapacbmr-a=SLeswb=SewaBet?iaposal SYU•paps 13d 17 f - Commonwealth of Mammehtne is Title 5 Official Inspection Form Subsurface Sewage EftMwl System Form-Not for Voluntary Assessments 716 Win Street BLDG. A Pmpety Address Vdlagp at Cotacheset Os owner's Name Wit' Osterviiie MA 02655 5-17-12 pae. for every ckyrro" Slate 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 maids Gomnents(note oorflt(an of soli,signs of hydrauNc fallure.level of ponding.condition of vegetation. etc. : tams•11110 Tfds 6 OtSckl kopecWn Fam:%tsurtm Sewa0e Dispose!8r5Mm•Page t4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Sebwdam Sewage Disposal System Form.loot for Voluntary Assessments 716 Main Street BLDG. A Property Address village at Cotacheset nequaed for every osterville MA 02655 5-17-12 page- cityrr— State Zip Code Date of fnspettiaot D. system information (cant.) 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 wrens within 100 feet. Locate where public wafter supply enters the building. Check one of the boxes below. 0 hard-sketch in the area below ® drawing attached separately i �I i tSns•1 rf10 Trsf�5 9l�sa!kespect6on F9�. �S�vl �'�•P�tS trt t; L0CAT10N _� ...� fit' - � f '+�IJ� GE � � RMIT N0. VILLAGE C)S i—��''L'''`i I N S T A LLER'S ?TAME A ADDRESS S9 V 1 L D 6 •d OWNER DATE P E P M I T 155UE1) DAT E C0MPl IAPICE 155UE0 C1.,,Plf„4 a s i ^ Commonwealth of Massachusetts Witte 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. A Property Address Village at Cotacheset owner ovows Narrte -- +equk al fore Osterville MA t'f2655 5-17-12 requHncl for every POW. C4lrown State Zip Code Date of Inspection D. System Information (coat.) Ste Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: OhtWned from system design plans on record If checked. date of d 1985 design plan reviewed: DWw ❑ Observed site(abutting property/observation Bole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: Q Checked with kraal excavators,installers-(attach docun�ln) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: GW off Plan Before filing this tnspectlort Report,please see Report CompWamess Checklist on next page. -1vrQ Tq*5 o "Weam FMTr SJcraos mega()Ee M"; -PW is of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form %bsu.fa"Somaip Disposal s,start Form-Not for Voluntary Assessments 715 Main Street BLDG. A Property Address Village at CotaGheset Owner OmmWs Name ice" 0steville MA 02655 5-17-12 page- a C41TOM state Z;p Code Date of inspection E. Report Completeness Checklist 0 Inspection Summary:A, B,G. D, or F checked 0 inspection Summary D(System Failure Criteria Applicable to All Systems)compEated ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file -i vt0 Ttna S on�a eres�ecmon wc.R S�eaoa D+acosao�•�t7 d t7 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Cotacheset Condominiums Property Address: 716 Main Street, Building A r _ Osterville. MA 02655 C) Owner's Name: First Property Management c3 _< "*`r Owner's Address; �JL 3�� co Date of Inspection: November 14, 2005 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford rn Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes NeerL Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: November 15, 2005 The system inspector shall sub .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 Continents ****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 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 716 Main Street, Building A Osterville, MA Owner: First Property Management Date of Inspection: November 14, 2005 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. Answer yes,no or not detennined(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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 716 Main Street,Building Osterville, MA Owner: First Property Management Date of Inspection: November 14, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. . 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool,or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,.performed.at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 716 Main Street, Building Osterville, MA Owner: First Property Management Date of Inspection: November 14, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ 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 'h 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 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 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 15303,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 System: 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 716 Main Street, Buildin A Osterville. MA Owner: First Property Management Date of Inspection: November 14, 2005 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: 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 15.302(3)(b)]. II 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 716 Main Street. Building A Osterville. MA Owner: First Property Management Date of Inspection: November 14, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 18 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: n/a-varies Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Varies Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied(some empty) COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 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: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street, Building A Osterville, MA . s Owner: First Property Management Date of Inspection: November 14 2005 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: ✓ (locate on site plan) Depth below grade: Approx. 18" 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) Dimensions: 4000 gal. -per information on file Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 5" 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: " How were dimensions determined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be anv signs of leakage Recommend pumping yearly for maintenance Steel covers were to grade. GREASE 'TRAP: None (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: Conunents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street, Building A Osterville, MA Owner: First Property Management Date of Inspection: November 14, 2005 TIGHT or HOLDING TANK: None (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): Aaann level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: ✓ if resent must be opened)(locate ( p p )( eon site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. The steel cover was to grade PUMP CHAMBER: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street Bui l ling,4 Osterville. 111IA I Owner: First Property Management Date of Inspection: November 14, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) I If SAS not located explain why: I Type ✓ leaching pits,number: 3- 1000.ea1. 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 hydrauliic failure,level of ponding,damp soil, condition of vegetation, etc.): I _Two of the pits 03 and#4)each had 6"ofliguid on the bottom The other pit 05)was dry There did not appear to be any signs o1failure. All ofthe pits had steel covers to grade. IThe bottom to grade was 13' There did not appear to be anyssigns offadure CESSPOOLS: None (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: I Depth of scum layer: Dimensions of cesspool: j Materials of construction: Indication of groundwater inflow(yes or no): Connnents (note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation, etc.): f I PRIVY: None (locate on site plan) j Materials of construction: Dimensions.- Depth.of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I i i 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street Building A Osterville, MA. Owner: First fro_per62 Management Date of Inspection: November 14 2005 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. e � � c � l � 0 POST' Al - iS_ J �Pa- So Aa- as Lp3_ ya A3- 3S 4.Py- 8S' g� 3a BPS- lad 10 f i Page I I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 Main Street, Building A Osterville, MA Owner: First Property Mana ement Date of Inspection: November 1.4, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have.been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 LOCATION SEWAGE PERMIT NO. j/(v PA t kx SJ . ULV rl `7-12 95 VILLAGE INSTALLER'S NAME a ADDRESS Co I k.C. �►` __�1��Jc t.6-1. IUA SS 8 U I L D E R OR OWNER fue �-(N S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED pLp,LD cur 37 � AL t At 99 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........ .ow.j...............O F....... :--..-.--------------_----- Appliratiaan for Uispvii al ivarkii a witrurtinn ami# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ....... Location ddress or Lot No. *Installer ._.. ._ -vI . 5 .....� .............: / ...../. --- ? --..t� vet-Cc� .... wner .---•Address U� •-------- - .......................... -------•-•••---•-•--.......------..... --•--•--••--------.........-•-•- ---..... Address Type of Build �� �� Size Lot..... 1�?._. �_..Sq. feet / V Dwelling No. of , _!� ..yxpansion Attic ( ) Garbage Grinder ( Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------- ------------------- d w Design Flow.................... , .. _. ._..._ gallons per person per day. Total daily flow....................... ?....gallons. WSeptic Tank—Liquid raacit .. _ _ allons Length................ Width................ Diameter................Depth............ xDisposal Trench—No.... ............... Width......: ........_.. Total Length............l...... Total leaching area....................sq. ft. Seepage Pit No._._.._...%3 _.. iameter......,. ... Depth below inlet............... Total leaching area...lib .Yq. ft. Z Other Distribution box ( � Dosing tank ( ) Percolation Test Results Performed by.....434'x, ,......JY9:..........•.......... Date......... . ....�-�1_.... a Test Pit No. 1.....-Z,..._minutes per inch Depth of Test Pit......., Depth to ground water...._":_ ........ GL, Test Pit No. 2........ per inch Depth of Test Pit------ ___.._.. Depth to ground water__ ........ a ••---•••••••-----------•-----------•-••-•...••••....••••---•------•-•-..._a.................................................................................. 0 Description of Soil.... ----- . . .............••• ------•-----.... ----•--•------------------- •---------------. --------- w ••--•- .40..0--------------------------------------------•------ UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..................................................•--------•---------------------------••...-•.•-••------•--•---•---••••-•--•••----•-•••-•••••-•-----••----•••-•-•-•-•-••••••--•--•-•••••-•--•••--•----- A eement +pplication undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with l� g g P Y ns f TI°'Y 5, the State Sanitary Code— The undersigned further agrees not to place the system in ti a f Compliance has been issued by the board of health GG Signed. . ...-. •- . .-. • �� 0. Date Approved BY•-• ---------••-------------------------- Date Disapproved for the following reasons---------------••----...----••--•-----------------------•-----------------------••-----------------.....-••-••--- ..-•••-•----•-••••---•--•-.....---•---•-••-•-•••......-•----•-----•-----....•-•..............••............ Date PermitNo......................................................... Issued....................................................... Date } Sal THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c ;. ............... .... �. �'� ..a.rf�`^. i �.. OF....... , pliraiott for Disposal Nor k� ott�txttrion rtni# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: )ql (t yam+ f /.��v - gy+ ��yy ikl - " Location�ddress �' or Lot No. 000 /f. +y�tt ^. `/C (�/ A !%i� „ f�' r+r i 'N 0, G�.i�YC` d`Or ............... .. J... _ .r... ...... _...._.._........r__ J ._{.....__......__......... ... 4 wner Address ------•- =--=•• F ••.............. . .........__._........ .......----••--••-•...__ ...---._...................._..._ -•--••......... .------... Installer � Address Type of Buildi >'?�,��Y15 Size Lot.............................Sq. feet Dwelling—No. of Bedrooms............._........... _ xpansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --•••----------------•-•-•••--•----•--....--•'---•--------••---------••---------••-•--------•----•-••-•-••••-•-.;---•----•---•••••--•-•---•- W Design Flow......................... __________gallons per person per day. Total daily flow...................... _ ' ___.gallons. WSeptic Tank—Liquid capacitydo�%'.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. _________ _____ Width___________________ Total Length............1....._ Total leaching area....................sq. ft. ( ( ) Seepage Pit No._.___._v..1.__.___. Iameter......�_�`___.___ Depth below inlet.___.;���_._._..... Total leaching area....."r_�.:�sq. ft. Other Distribution box Dosingtank aPercolation Test Results Performed by. - k 1Z _ a_____________________ Date____.._._ ' a Test Pit No. I.....7w_.._.minutes per inch Depth of Test Pit........ Depth to ground water______"""_____________ Test Pit No. 2....... ...__minutes per inch Depth of Test Pit_____ ___ ________ Depth to ground water.__�✓1,e __-______- R+' •-----•-----•--•---••--•------•-•--•-•_--- ----•--•---••-•••-•_... ••-•-•.......---•-...-•-------------•••••-....-••------••••--------•••..-----•---_••••. O Description of Soil.................... / ________ U W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...............................................--•-••••--•------•--------••---•-•..............•-•••-•-•-••-•••------•--------•----•--••----••-•--•-•••--•-•-•-•-------•------•--------•......._-••--=• A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t provis}ons f T IR T 5pf the State Sanitary Code— The undersigned further agrees not to place the system in erati 'unt• a ifi 6ff Compliance has been ``issued by the boardaf/of health A v. Signed �i.�� ��•--9~' 9 G x::�. �'-------- DateC n Approved By o �i ------------------------............... Date PPlication Disapproved for the following reasons----------------------------------------------------------------------------•---------------------••--•--_...-- .......................................--•-•---•-•--•--•-••••••-----•••--••---•-._......._..--•-••--••--••-••-•-•••--•••••--•----••----•••-•-----•••-------•----••----••----•-••••--•-•----••-•--•-••-- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C.5rdifiratr of TootlrliFattrr THIS IS TO CERTI Y� That the Individual S wage Dis osal System constructed ( ) or Repaired ( ) by.. a... y _r= '' v` .--)-------------------------------------------------------------------•------- A.{,q j1 p Tli t y,, - ------Installer L!t ----�-- ..-•----..............L""'r •1'.:15.--��-��------• ..a`..?-P;y���"4..•z ,� - -----------------•- \ ` •-------•----:_....--------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as-described in the application for Disposal Works Construction Permit No............ _ .... dated-..------- ........ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W F4NCT N SATISFACTORY. DATE ......... ................................................... Inspector...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j..r7`v% {...............OF........ ..........................tcgd'1 ��.....__........ .._.. L) No.: (1 FEE.._. Z?.......... i ros�tl� o Cott tr --; - �2 . P Permission is hereby granted----•-----==" == -=`:: =''�. -• ... to Construct ( v)cr Re air ( ) an Individual Sewage Disposal System at No................�=! .J�_.!._apt_...-?I .............. ----------- _- ----- Street ...... as shown on the application for Disposal Works Construction Permit No..9...__ Dated..__ �p __' �� �...-•- DATE....... tqg Board of Health • 1 vv FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ce Y- • No. �2&9 Fes$.... . ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF...... � ... firation for Disp.a,oul-: park '"trurtiutt rrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: o ation-Add As or Lot No. - _-.1 .__�:..-;1:W..1A...... .-� I ..................................................... k O e Address Installer Address Type of Buil'din 3 Size Lot.__.�tj V ..Sq. feet U Dwelling—No. of Bedrooms...................... .�-�f���Expansion Attic ( ) Garbage Grinder -- Other—Type of Building No, of persons............................ Showers — Cafeteria a' Other fixtures ......................................................... -------------------------------------------------------------------------- W Design Flow......................545...........gallons per, person per day. Total ,daily flow............................ WSeptic Tank—Liquid*capacit allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length............. Total leaching area....................sq. ft. Seepage Pit No.......�-_-__-- iameter........1 ... Depth below inlet---............ Total leaching area..,l.S1/&. ft. Z Other Distribution box ( Dosing tank ( ) Am � Percolation Test Results Performed by..V�.*.J� m....__ ...... Date........................................ Test Pit No. 1..... .._.minutes per inch Depth of Test Pit...... _ -- ___ Depth to ground water.._ fT4 Test Pit No:2------ ....minutes per inch Depth of Test Pit...... _. Depth to ground water...... .. .......... Q+ .......................=..................................................................................................................................... 0 Description of Soil.............................................................. .......--------...------. ----- ----•------------------------------•------------------- U .----------- ........•---------- ..1�1y..[ ----f7.��.t=��L-a4d.._........ ..._._...- �41Y----Yf.'.!'..W_�................................---••-•-----•-----. W ----------------------------------------------------------------------------------------------------------------------------------------------------•------...........---..........._..._._._._......... U Nature of Repairs or Alterations—Answer when applicable...__........................................................................................... •-------••-•......................................•-----•---------------------..........----------------------•----•----------------•------------------•----------------------------------........_.---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with th prov ion of of the State Sanitary Code—The undersigned further agrees not to place the system in ra ' n it ti a of Compliance has been issued by the board of�iealth. Signed... ... .. ............... L a D e p'cation Approved BY-....-- �•------•----...�''�t.:................. ...................................... ---• ..... -- -- ......... � Dat Application Disapproved for the following reasons--------------------------------------------------------•---•-•------------------•-------------------------•••••. -•...............................•-----•--------------------...--••-----••-------•---•-----•-------....-----------------------------------------------------------------...----------------------------- Date Permit No......................................................... Issued_....................................................... Date No... � :.. Fes$.....' .` .._ THE COMMONWEALTH OF MASSACHUSETTS ---- BOARD OF HEALTH 1 P tt�, ,#. : OF......r .............................s.. ' z......:!;,`------------------------•------ Appliration for Disposal Works Tontrurtion Frrmit Application is hereby made.for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: 1 �='t--r_.;;1-------..•;> &� , ..................L .4 !__. r Location-Add}lss ] �r Lot No. :'F£.._V=t� -,-- !:�i tl 1�._....X � #1 i 1.-----------•--•...............- --------•••- -•---•--- rt-._......._ .............................................. a 0�� �� Oy ner Address ti ---- . ...--•-•-••--------------------•. ..................................................................................................---...--••----------•----••--•---...-•------- -------•....--•--............--•-•••._..........._. Installer Address d Type of Buildin 3 IFUZZ&VI-rgSize Lot..................... ...Sq. feet Dwelling—No. of Bedrooms____________________� 4�7� Expansion Attic ( ) Garbage Grinder Other—T e of Building ............................ No, of persons____________________________ Showers — Cafeteria p•l g Other fixtures ;,....------•- •--•-•-•-• --•- •--•------ -•-.••--- ----•-••--•----•--. -------•------••-•-•---•----•......;� .•-gal-_•---- W Design Flow......................_ gallons per person per day. Total dailyfl ..... Ions. WSeptic Tank—Liquid capacit gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.___________________ Width_____.._.:_........ Total Length.............`..... Total leaching area....................sq. ft. Seepage Pit No........ _______ Diameter........ Depth below inlet..... Total leaching area_.¢ �gsq. ft. Z Other Distribution box ( d Dosing tank ( ), Percolation Test Results Performed by. ____-y__t;ty #___._._g(.-:%_:.:..____�_..______ Date........................................ `4a Test Pit No. 1..... ____minutes per inch Depth of Test Pit......1.2-7.... Depth to ground water.__:':":":"`__ fz, Test Pit No. 2......2 .__._minutes per inch Depth of Test Pit...... ':.._ Depth to ground water......k ......... ---------------------------------------------------------•-----------._......_.._---•-----•.......-•......................................................... O Description_ of Soil............................................................... � JJ --------- -- --------•--------------- _________---- : W ....................................................7 __________.________..................................................................................._____._____!___._______.................. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•-------------•-----•-----...••--------•••----••--•--•-••----•--•--••-••-•--._...........•••--••••-•--•••-••--••••••--•-••••------•------••••---••••........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with /�thj pro v' iong Of'yIT of the State Sanitary,Code—The undersigned further agrees not to place the ystemiin era nYt til a/ erti e of Compliance has been issued by the beard of iealth. ' Signed_.__'� _. !...-----'� -�`� �1 .a_._ __� .�... ;n p cation Approved By--------------- !k, :_.. •----••----• Dat �r V�PPlication Disapproved for the following reasons:................................................................................................................ ..................•-••--•-----••••-•-••-_....----...•-------------•-•------------•----•------------------I-------•----•--------•--------•-•--•......-------•-•---•••--•••---•••-------•••--•-------_----- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS r---'° BOARD . OF. HEALTH Trrtif aratr of Toutplianrr THIS IS O CERTIFY, That the In :vidual Sewage Disposal System constructed (Z) orRepaired ( ) by---•-•-----+-----•--------- • _•-••-•-•-•.hP....... , -----------------------------------•••-•-_____-----•--•-•-------•--------------- 1 A !•� 9 z i �j� 9 `i hy'z ✓��nstaller � ),E�!.1._�_. ` — �e�.at.-----•_...:......-•-••---•- ---------. ------_•-•_••. ------. -•-•--•. ---••-. .............•----•-----------•--------••••- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 9d as described in the application for Disposal Works Construction Permit No._....--.` ... �.�..._' dated__.z::V. - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE SYSTEM WILL. FUNCT O SAT SFACTORY. DATE................................... (?...................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F.' HEALTH i , No. .� _...... FEE. ". 'Disposal Mods Tonotra ion rrmi Permission is hereby ranted__.._ � __.... A C..TC> ....__...---••----•--•-------••-••-•------••••----••••--•--••.._..._._..-••••-•...................._------ to Construct fs,Kor Repair ( ) an Individual Sewage D*osal System at No..•---•_.... -: 1/ ____ _....._.t ..ST.1 `` •-�-------�-----.......... (Ji�I ............................................................... Street .. as.shown on the application for Disposal Works Construction Permit No. �"�t.. Dated......L�j� ___ 411.............. J''• ............................. ...... .......................... Board of Health DATE------ ------5 .t...1 ! -------•--------------• t FORM 1255 HOSES & WARREN. INC.. PUBLISHERS t CQTq C, tSC, r OAd ' TOWN OFQQBARjJNSTABdLE LOCAn&,N 1�o /1'1Atr1 A(�1c'1A P /�7 SEWAGE # VILLAGE O.ST ry, ASSESSOR'S MAP & LOT /y/ 037 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �UIiD LEACHING FACMITY: (type) 3 " IM 541, (size) NO.OF BEDROOMS BUILDER OR OWNER C 914-LAtst COK a A V. PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a Sptclen �. �e - s$ -hd, ph -Ed7 i °S -ed 7 ' %h -Id7 .Lsoof Jwtw7l I f TOWN OF B STAB E L•.J'--A8���i i.L r 2' SEWAGE # V11.LAGE ASSESSOR'S MAP & LOT y/ a /iKSpVcsr/�S TtSM NAME&PHONE NO. A/ Jf`/GG/Z SEPTIC TANK CAPACM LEACHING FACILITY: (type) 3 (size) IV � P NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3.73/ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �� �=Gc 8 � I L Ly,e"P��T Aw,-r 4, 6, G h TOWN OF BARN /3v1 o�,-1 y STABLE LOCH'."I7N r l �' SEWAGE # (� �n VILLAGE J �MAp �.J SdS IN� a �41SSESSRt & LOT NAME&PHONE-NO. SEPTIC TAN CAPACTIvY -�- LEACHING FACILITY: (hype) 7S (size) �f NO.OF BEDROOMS f 1 BUILDER OR OWNER ------------ PERMITDATE: COMPL LANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 3. 23 Feet Private Water Supply Well and Leachin Facility ty (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300_feet-of leaching facility). - Furnished by Feet I. _ I 1 is iq:5:o1Z. i �4 C.��Se- ..00^6 1TOWN OF BARNSTABLE LOCATIONl�oAtrt SEWAGE # VILLAGE_ Q.S7er, t ASSESSOR'S MAP'& LET/47 -I3.7 INSTALLER'S NAME&PHONE NO. - I SEPTIC„TANKvGAPACITY LEACHING FAC_LITY: (type) -- �Qa'� �i�QI (size) NO. OF BEDROOMS f I BUILDER OR OWNER C O ,�5. / 5 ei CowCb � I PERMTTDATE: COMPLIANCE DATE: - I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fee' t Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) r Feet Furnished by�lji�rc.Tp„ . . �, Fn.� I . p . a f. t � S y 3 ' I c,a,r,P post, API Q1(60 • - r Al TO as A3+ 3S py � c 3a i L 0 C A I0N S.f W-A .G E PERMIT NO:. VILLAGE INST. AALE-R'S NA-ME i ADDWES.S i �oC3�T �. OU+Z- Co ��C• F � • i l 4 R U-1 L D E R OR OWNER f Ult A t cc-, MA f . DATE PERMIT ISSUED D A T E C0MPLI-ANCE ISSUED _ 3 39 l i f i MM I "Jo A 1 r a 7'7 v 5 ( -Z AA WN lav- nff . . tL. Piro loo _.._. .. ! eP 1 vtA £ / ,.✓ Tv 2Y'4AG (( J1 iP ;Pei C'Ari ur'c ULI (T i t -- ! f•rl )j! � , ' ��� l ��G'�r�v�r"1'• 'r, �ov�'Iv s� 1'TLQ�� ��.._...u..�' :5��1�• `'��'�r��"�..�.. .. 1 d 1 -70 I _ ,+^'"`�_ kc .'''' �•�• � `47 ,! , � - Ili ___.� -- "-�«,• �' -- �(J�����1 '� � � ° �'�"�. -, way^�'�• � - IL ko _ F(,,• 1 / / // � .� '� P ��"YrP���`$"tr'S�,,:rauvRt+vi�'fa�'�friYe;yflr'J+fM^{� i 7' ' _ c-".�F"iF,+Y^.,a..�,.,,r./�:'.�`__..,,'K..,,.w_ ,,.e,%r�' `Oi•yg,,,,� LJ'� �L 40 lot Frr f I � •l � ""`\ � Y ..r� M!r+�&� ,� I ,•r�f� �r.1G�.,�, lGC?'�' v►"i` ��I .. ! / ! g 7 � . .--• , �� K '� I f j `." "�'7..t� I ��. �'•� 1 El flt f GAG � 1 k PF �'dt0 �f t�J � r L� I •-•r A d1 �? ,a '"�` +'�-� .:J1.'a.. 1. Is A2e.4 47 I-A ? f Ajo ( AQA b� pig 4, f�; f I t04. NtJL'�"1 rQ y ,r 1 -_... _�••—• _ � , � i Z 4PD }. %/� 2. "Ip 4t r Q ... lr�.�(.. f�/ t ``� • A ^_ �ry T e0l. P' fTAsW�+.U... jlg PIT"' 4 r7�,1 2 �^►'�'f 11�. I,,,w�^""""�`� ....t,,,ti ''�'""L'�- 1 �\ r l r•`,.� ,.•� �' r� .l I �/ � r f 1.!. V d d..- t +t 1.t12j N � Nit ' } F3it;MARU •cat� A. 'a'.:� �+''. '�, It Q { i