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HomeMy WebLinkAbout0716 MAIN STREET (OST.) - Health Wr716�6-1---B-D�6in.Str-ee'i (Ost.) j Osterville `tP _ - i A 141 037' J , t i 3 r 600 Commonwealth of'Massachusetts Title 5 Official Inspection Form �0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 'C u/ 716 Main Street(Bldg B) �+ 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 �t S„ I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms. on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Sears use the return Name;of.lnspector key. Robert B Our Co INC. r� Company Name 363 Whites Path Az Company Address 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: OF ® Passes ❑ Conditionally Passes ❑ F ' sNo MICHAEL �= ❑ Needs Further Evaluation by the Local Approving Authority _o i SEARS * No.SI14430 y 8-31-20 �'��.,F 5 IN S?lp_-. � Inspector' ignature 'Date ur°i°mt� 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 1.0,000 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r. Commonwealth of Massachusetts Title 5 Officia pecti®l lns .n Form } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 716 Main Street(Bldg B) 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 _ B. Certification (cont.) Inspection Summary: Check A,RIC,D or E/always complete all of Section D p rY 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 H-20 pit's. B) System Conditionally Passes: X ❑ 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 over20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying.septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of.Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.=,Not for Voluntary Assessments � 716 Main Street(Bldg R) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osteryille - MA. . 02655 8-31-20- page. Cityfrown 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 ofr 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): El 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): El broken pipe(s)are replaced- ❑ Y ❑ N ❑ ND (Explain below): k ❑ 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 failing10 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 , C Commonwealth of Massachusetts +� ,p Title 5 Official � I;nspecti®n Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 716 Main Street(Bldg B) u Property Address Cotacheset Village Association Owner Owner's Name x information is required for every Osterville MA - 02655' 8-31-20 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 " ❑ p Y 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 co.liform 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 ElBackup 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 El or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less El than '/z day flow Page 4 of 17 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:;Subsurface Sewage Disposal System• a Commonwealth of Massachusetts �n Title 5 Official Inspection Fo.rm- �I� Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name d;: information is required for every `Osterville MA 02655 8-31-20 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(§). Number.of times pumped: ® Any portion of the SAS,; cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ` ® tributary to a surface water supply. °❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private,.water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform,bacteria-indicates absent and the presence of ammonia nitrogen and nitrate,nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- El ®-1 ,. -. 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; 'El ❑ 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 ProtectionD El , 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.doc•rev.6/16 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts { Title 5 Official Inspection Form FiI� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) 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 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 ❑ Z 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? - f. ❑ ® Have large volumes of water been introduced to the system recently or as part o 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? ® El information 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts p, Title 5 Official Inspection Form yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) 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 Description: The system is a 5000 Gal H-20 precast tank D Box and 3 leaching 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. El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) V 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 D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: November 2016 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 l ❑ Overflow cesspool ❑ Privy, ❑ Shared system(yes or no) (if yes, attach previous inspection records,.if any) i 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 8 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments i r 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner .'.Owner's Name information is required for every Cisterville 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): feet grade: Depth below : e p g et Material of construction: ❑ cast iron ®40 PVC l ❑ 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 SCH 40 PVC. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: E$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 5000 Gal. Precast Dimensions: 2„ Sludge depth: l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts k' �n Title 5 Official Inspection Form re �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) u Property Address Cotacheset Village Association Owner Owner's Name information is sere MA 02655 8-31-20 required for every. Otyill ';1 page. City/Town State Zip Code Date of Inspection, D. System. Information (cont.) 4 Septic Tank(cont.) Distance from top of sludge to bottom-of outlet tee or baffle 36 Scum thickness - 8" , Distance from top of scum to top of.outlet tee or baffle Distance from bottom of scum tojbottom 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 &out-let tee's in place. Both cover's are steel at grade.No sign of leakage or over loading • H Grease Trap (locate on site.plan): Depth below grade: feet Material of construction: E] 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: w pate t5ins.doc•rev.6/16 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:_° 716 Main Street (Bldg B) 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(coat.) k Comments (on pumping recommendations,,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidenceof.leakage, etc.): Tight.olr Holding Tank (tank must bepumped at time of inspection) (locate on site plan): Depth below grades Material of construction: El concrete El metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: " gallons per day Alarm present: ❑ Yes ❑ No Alarm level:, Alarm in working order: ❑'Yes ❑ No Date of last pumping: Date Comments.(condition of alarm and float switches; etc.): Attach copy of current pumping contract.(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5,0fficial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form FIII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 716 Main Street(Bldg B) 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 clean and solid, 30" below grade. W/steel cover at grade,three lines out. No sign of over loading or solid carry over. 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form 11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments >r; V � 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is Osteryllle MA 02655 8-31-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: . 3 ..leaching pits number: ❑ 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 three1000 Gal. pits. W/2' shim and 4' stone per plan. All pit's have steel cover's at grade 6"water in pit's No sign of over loading or solid carry over. ' 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 r Depth of scum layer Dimensions of cesspool Materials of construction Indication'of groundwater inflow ❑- Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1_ iI; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .............. !% 716 Main Street(Bldg B) u Property Address Cotacheset Village Association Owner Owner's Name information is MA 02655. 8-31-20 required for every OStervllle page. City/Town State, Zip Code Date of Inspection D. System Information' (cont ) Comments (note condition-of soil„signs of hydraulic failure, level of ponding, condition of vegetation, etc.): { Privy(locate on site plan):. Materials of construction: n Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,.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 f Commonwealth of Massachusetts Title 5 Official inspection form Subsurface Sewage Disposal System Form Not for Vol unta ry,Assessments u % 716 Main Street(Bldg B) Property Address oe p Y .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.) 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 10.0;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 I Commonwealth of Massachusetts Title 5 Official Inspection Form k .I�� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street(Bldg B) t 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 D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 12V Estimated depth to high ground utater. 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: t f ❑ Checked with local excavators, installers- (attach documentation)_ ❑ Accessed USGS database -explain: You must descr6e 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. t5ins.doc•rev.6/16 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 1 f— Commonwealth of Massachusetts ' r - �� Title 5 Official Inspection Form �i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 716 Main Street(Bldg B) 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 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.doc-rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•,Page.17 of 17 Aug 18 20,01:39p Capewide Enterprises 5084774977 p,15 t Feb 01 IS:09;45a Capewide Enterprises 608-477-49717 o At- /, a- qY a,a- 3 A 3- AT 03- Sa 2 AV- !r9f a-Y- s� - As '►� 8S $f i } i } I k t i i Lb a5ed xej idH tv:OZ BIOZ Ll 03 l , xl-o3-7-ooA Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 13.,E 716 Main Street(Bldg B) r=o3 Property Address Cotacheset Village Association Owner Owner's Name / a_ information is Ostill M erye ✓ A 02655 2-5-18 required for every page, City/Town State Zip Code Date of InspectionLr Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information /a 039 �pnuuuurp� on the computer, �\\\\� 10 GF M use only the tab `�4�'• ASS9''�i, 1. Inspector: key to moue your �O?� •'•yG cursor-do not James D. Sears JAMES '.Ln e the return Name of Inspector ; key. :y R Y Capewide Enterprises, '*' r y Company Name -,P CN T IOS�� 153 Commercial Street Company Address Mashpee MA 02649 Clty/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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-9-18 nspector'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. t51ns.doc•rev.6r18 - Title 5 official Inspection Form;Subsurface Sewage Disposal System•Page 1 of 17 .La�ed VS Z a5ed xeJ dH WOE 260Z 1.6 9aJ Commonwealth of Massachusetts n. Title 5 Official inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j� 716 Main Street(Bldg B) `1 Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont,) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 5000 Gal. H-20 Tank D Box and three H-20 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): tsins.doc-rev.6/16 Tile 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 £ a5ed xe:1 dH WOZ 860Z qaj s 5 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street(Bldg B) 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 (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cons): ❑ 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.doc-rev.6116 Title S Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 a5ed xed dH WOZ 860Z 66 qaH f c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tiE 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner G+wner's Name information is required for every Osterville MA 02655 2-5-18 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 is less than 6" below invert or available volume is less than '/z day flow P,7'S' 15lns.doc rev.6116 Title 5 Official InapecGon Form:Subsurface Sewage Disposal System•Page 4 of 17 5 a5ed xe:1 dH Ob:OZ 860Z 66 9�J i Commonwealth of Massachusetts LTitle 5 Official Inspection Form iSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name Information is required for every Osterville MA 02555 2-5-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year Nor 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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.doc•rev,6116 Title 5 Ofhdal Inspection Form:Subsurface Sewage Disposal System•Pne 5 of V 9 a5ed xed dH Ob:OZ 8 60Z 6 6 qad c Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 716 Main Street(Bldg B) 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 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) 1310 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.61'6 T11W 5 Official InspecUon Form:Subsurface Sewage Disposal System•Page 6 of 17 L a5ed xe� dH 6b:0Z 81.0Z 66 qad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 5000 Gal. H-20 precast tank, D Box and 3 leaching 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 Seasonaluse? ❑ 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: PresentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personslsq.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 InsW_fioA Forth:Subsurface Sewage Disposal SyMerr_-Page 7 of 17 g a5ed xe:1 dH Lb:OZ 860Z 61, qad I , Commonwealth of Massachusetts 9� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2.6v", 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: 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): 15ina.doc•rev.614.6 Title 5Official Inspection Form;Subsurface Sewage Disposal System•Page 8 of 17 6 a5ed xed dH Zt,:OZ 860Z 1,1. q6d i Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 page. CitylTown 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): 4' Depth below grade: 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" SCH 40 PVC. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal El 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: 2" t5ins.doc• aJ16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 0l, a5ed xed dH Zt7:OZ 81.OZ 1,. Gad i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655 2-5-18 required for every Cit /Town page. y, State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1' 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 wlin&out let tee's in place. Both cover's are 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 Ifte.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 66 abed xed dH Zv:oe 860Z 66 qad I Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Cisterville MA 02655 2-5-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont,) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.); Tight or Holding Tank(tank must be pumped at time of inspection) (locate an 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.6J16 This 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Z6 a6ed xed dH £b:OZ 860Z 1.6 clad Commonwealth of Massachusetts 62 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 Paw. 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 clean and solid, 30"below grade.W/steel cover at grade,three lines out. No sign of over loading or solid carry over. 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. Soll Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.Ell Title 5 Official h5peotion Forth:Subsurface Seweje Oisposel System•Page 12 of 17 £l a5ed xed dH £b:OZ 860Z Ci, 9a� Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owners 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.) Type: ® leaching pits number: 3 ❑ 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. pits. W/2'shim and 4'stone per plan. All pit's have steel cover's at grade. 6"water in pit's. No sign of over loadinq or solid carry over. ' Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins.doc•rev.6!16 Tate 5 Official Inspection form'.Subsurface Sewage oisposal System•Page 13 of 17 b 6 abed xeJ dH £t7:OZ 8 60Z G t qaJ Commonwealth of Massachusetts Title 5 official Inspection Form 's Subsurfaee Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) L Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-16 page, CitylTown 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.doc-rev.6116 Tllle 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 14 of 17 5 abed xed dH £t,:OZ 81.0Z 61• 9ad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is required for every Osterville MA 02655 2-5-18 paw. 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 16Ins.cloc•rev.M5 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 9 t abed xed dH t V:0Z 2 60Z 6 6 q@d Feb 01 18,09:45a Capewide Enterprises 508-477-4977 p.1 n t(o gal al +71 �'• ti' 8 y . AI- 3b Qf"� Aa- QT A 3- aS 83 fa A ly � S L6 a5ed )(eJ dH tlt,:OZ 860Z 66 qaj Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655 2-5-18 required for every page CityfTown State Zlp Code Date of Insped!on D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Nr Estimated depth to hi tt gh ground water: fee+' 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 plan Site high from road Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins.doc•rev.&16 This 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 g 6 a5ed xed dH bbU S 60Z 61, gad Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 716 Main Street(Bldg B) Property Address Cotacheset Village Association Owner Owner's Name information is Osterville MA 02655 2-5-16 required for every Ci /Town page. ty 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 6 6 abed xed dH VVU 8 60Z 6 6 Gad Commonwealth.of Massachusetts" Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments M 716 Main Street BLDG. B 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 filling out forms A. General Information ma's �FrAf4 on the computer, L �� l use only the tab key to move your 1. Inspector: a`�:' JAMES cursor-do not �m use the return James D. Sears _rI - key. Name of Inspector 0 :v, Capewide Enterprises, LLC • Company Name 153 Commercial Street i�����' l5!IN SIP"—`\ Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 31623 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. O� t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B Property Address Village at Cotacheset Owner Owner's Name information is required for every Osterville MA 02655 4-13-15 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 5000 Gal. H-20 Tank D Box and three H-20 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 at 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B 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.) B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑' Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B 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.) 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in conspoW is less than 6" below invert or available volume is less than %day flow A,7-.S' t5ins•11/10 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 716 Main Street BLDG. B Property Address Village at Cotacheset Owner Owner's Name information is Osteryille MA 02655 4-1.3-15 required for every . page. Cityfrown 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 N 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 1.5.303, 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 e 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 ' t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B 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 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•11110 Tile 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 , i Commonwealth of Massachusetts c usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B 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 leaching 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 r 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 Industrial 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 M ,•�''p 716 Main Street BLDG. B E Property Address Village at Cotacheset Owner Owners Name information is Osterville MA 02655 4-13-15 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: ` 5/9-5/10-4112 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 716 Main Street BLDG. B Property Address Village at Cotacheset Owner Owner's Name information is Osteryille MA 02655 4-13-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1985 Permit # 85-268 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 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"SCH 40 PVC- No sign of roots or brakes. Septic Tank(locate on site plan): Depth below grade: 31feet 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 716 Main Street BLDG. B 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 (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 2" 81' 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 in place, Both covers are 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 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. B 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(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.): r ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 716 Main Street BLD G. B 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.) 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 clean and solid, 30"below grade. W/steel cover at grade. Three lines out. No sign of over loading or solid carry over. 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:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 716 Main Street BLDG. B Property Address Village at Cotacheset Owner Owners Name information is Osterville MA 02655 4-13-15 required for every page. City/Town 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/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 Pits,W/2'shim and 4'stone per plan. All pits have steel covers at grade. 4"water in pits. No sign of over loading or solid carry over. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts lugTitle 5 Official Inspection Forma Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B 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.) 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-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 716 Main Street BLDG. B 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.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 A;,- of 3 A 3_ ;L$ 83, S� 13 14 , -_..... Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 716 Main Street BLDG. B Property Address Village at Cotacheset Owner Owner's Name information is Osterville MA 02655 4-13-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells IVO 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 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 V 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 I Commonwealth of Massachusetts V Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 716 Main Street BLDG. B 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 I , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f� 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 B Osterville, MA 02655 O Owner's Name: First Property Management ICC CZ V �� Owner's Address: ,�' � tt� p Date of Inspection: November 14, 2005 C) = cr; Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford �co Mailing Address: P.O.Box 49 t 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 Nee Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: November 15, 2005 The system inspector shall sub 't 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 1.0,000 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 I . i r 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 B _ 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 r 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 B Osterville, MA Owner: First Pro erty 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 anunonia 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 t 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 B 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 ''/z day flow ✓ Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped—. ✓ Any portion of the-SAS,cesspool or privy is below high 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 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 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 shall upgrade the system in accordance with 310 CMR 15.3.04. 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, Building B 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)], 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 716 Main Street. Buildinv B 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 empbj C OMMERCIAL/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 V 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 v Page 7 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 B Osterville, MA Owner: First Proper Mana ement 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. 2' 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 Qal. -ner information on Me Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 8" 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 any 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: Comments(on pumping,recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f • i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DiISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street, Building B Osterville, MA Owner: First Pro erty Management Date of Inspection: November 14, 2005 j 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 1 fiberglass _polyethylene _other(explain): i Dimensions: Capacity: gallons j Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.) I I DISTRIBUTION BOX: ✓ .(if present must be a,'pened)(locate on site plan) Depth of liquid level above outlet invert: Even I 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. No solids aesent. The steel cover was to zrade. j i i PUMP CHAMBER: None (locate on site plan) i Pumps in working order(yes or no): j Alarms in working order(yes or no) Comments(note condition of pump chamber,conditions of pumps and appurtenances,etc.): i i i j I I I 8 I 1 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS AL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street Building B Osterville, MA Owner: First Property ManaZement Date of Inspection: November 14, 2005 SOIL ABSORPTION SYSTEM(SAS): . ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 3- 1000¢al. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Continents(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Two of the pits 03 and#4)were dry, The other pit 05)had 6"of liquid on the bottom There did not appear to be anv saQns of failure. All of the pits had steel covers to Qrade The bottom to rade was 13' There did not appear to be any signs offailure 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: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Continents (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 z .Page 10 of 11 i I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street, Building B Osterville, MA Owner: First Propertv Manage�'nent Date of Inspection: November 14, 2005 I 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. Locat where public water supply enters the building. I I i i I I j i (3°1 (3to ISO eta 6� Ay J Y 3 . 3 A 3_ ag 63- Sa fay- -,y t35- y S . 10 i Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFA CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 Main Street, Building B. Osterville, MA Owner: First Property Management Date of Inspection: November 14 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 tnaps 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 naps were showing approximately 20'+/ to Around 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 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P OTC-CUMNED JAN 0 6 2061 TOWN OF BARNSTABLE HEALTH DEPT. 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 B Osterville, MA 02655 Owner's Name: First Property Management Owner's Address: Date of Inspection: December 17, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 141 Osterville,MA 02655-0049 Parcel: 037 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: December 20, 2002 The system inspector shall sub fa copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****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 B Osterville, AM Owner: First Property Management Date of Inspection: December 17, 2002 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 determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is,imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND explain: ✓ Observation of sewage backup or break out or high static water level in the distribution box.due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed ✓* distribution box is leveled or replaced *The D-box was broken and dirt was caving in. Needs replacing. 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 B Osterville, MA Owner: First Property Management Date of Inspection: December 17, 2002 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: i 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 f 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 B Osterville, M4 Owner: First Property Management Date of Inspection: December 17, 2002 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 '/z 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 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 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 716 Main Street; Building B Osterville, AM Owner: First Property Management Date of Inspection: December 17, 2002 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? i ✓ _ 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)]. 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 B Osterville, AM Owner: First Property Management Date of Inspection: December 17, 2002 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 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes,separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Ud 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: Pumped yearly-per management 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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 Main Street, Building B. Osterville, MA Owner: First Property Management Date of Inspection: December 17, 2002 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. 2' 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: 10" 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 were no signs ofleakage. Recommend pumping every year for maintenance. The 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 f 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 B Osterville, AM Owner: First Property Management Date of Inspection: December 17, 2002 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 p ty� Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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 broken down. Dirt was caving in. The D-box needs replacement. 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 ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 Main Street, Building B Osterville, MA Owner: First Property Management Date of Inspection: December 17, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 3- 1000 gal. 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.): One pit 03)had approx. 6"ofwater on the bottom. Another pit(#4)had approx. 6"of water on the bottom. The other pit 05) had approx. 6"of water on the bottom. There were no signs of failure. The bottom to grade was approx. 13'. 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: Depth of scum layer: Dimensions of cesspool: Materials of construction: .Indication of groundwater inflow(yes of no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 I Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 Main Street, Building B Osterville, MA Owner: First Property Management Date of Inspection: December 17, 2002 Map: 141 Parcel. 037 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. l �0 841 Ay � via Aa- y8 aa- �3 3 A 3- ag 83- Sa a Ay- f3zi- y S 10 Page 11 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 B Osterville, MA Owner: First Property Management Date of Inspection: December 17, 2002 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 the Barnstable topographic map and the Cape Cod Commission water contours map,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 � . t COMMONWEAL'I'II OF MASSACILUSE'.l"I'S - NVIRONMENTAI,AF L'XECU IVE OFFICE OF L _ = -- - Wi'PARTMLN`L' OF ElNVI_RONMRNTA , TROT (' ON ONE WINTER.STRF.,I T, IIOSTON MA 02108 (617) 292-5500��' ;10% ' ft 71U Y ,,OXF, et:,ry 350 MAIN STREET nlu;ro PnvL ci l,l,vccl WEST YARMOUTH, MA vnvI B STRUMS Governor 508-775-2800 munssioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 141 PAR 037 PROPERTY ADDRESS: 716 MAIN STREET, OSTERVILLE BLDG B ADDRESS OF OWNER: DATE OF INSPECTION: DECEMBER 15, 1999 VILLAGE COTTAGE ASSOC. NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: its DATE`:. The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or'DEP) within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. y. NOTES AND COMMENTS: REPORT 2 OF 2 SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 716 MAIN STREET, OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. r Date of Inspection: DECEMBER 15, 1999 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: YES I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A i One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 716 MAIN STREET,OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS;UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER fl revised 9/2/98 3 ra SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 716 MAIN STREET,OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 D]SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- - loaded 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'Y2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone 11 of a,public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 716 MAIN STREET, OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was, inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information.Ex. Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. E r revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 716 MAIN STREET, OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 FLOW CONDITIONS RESIDENTIAL: YES Design flow: g.p.d./bedroom for S.A.S. Number of bedrooms(design) Number of bedrooms(actual): Total DESIGN flow Number of current residents: N/A Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): N/A If yes,separate inspection required Laundry system inspected(yes or no): N/A Seasonal use(yes or no) SOME Water meter readings,if available(last two(2)year usage(gpd): UNAVAILABLE Sump Pump(yes or no): NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow: Gpd(Based on 16.203) Basis of design flow Grease trap present:(yes or no): Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1994,1996,1996,1997 BARNSTABLE PLAND System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: 1985-86 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 MAIN STREET,OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: 2' ' Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 4,000 GALLONS Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined TAPE&AS BUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,3 INLET TEES,1 OUTLET TEE BOTH COVERS 2'STEEL AT GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction concrete metal _ Fiberglass _ Polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98 7 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 MAIN STREET,OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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 Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: YES (locate on site plan) Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) BOX IS 28"BELOW GRADE,30"X 30"BOX ONE LINE IN,THREE LINES OUT BOX IS CLEAN,T STEEL COVER AT GRADE PUMP CHAMBER: N/A (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.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 716 MAIN STREET, OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 3 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: " (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)" THREE PITS,PIT 1 —6'BELOW GRADE T DEEP PIT 2-6'BELOW GRADE T DEEP PIT 3—5 BELOW GRADE T DEEP ALL THREE PITS ARE DAMP, 2' STEEL COVERS AT GRADE CESSPOOLS: N/A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.) PRIVY: N/A (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.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: 716 MAIN STREET, OSTERVILLE BLDG B Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) r g 1 n 09 3 --.� o Fz sy s., s revised 9/2/98 10 s` a, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 716 MAIN STREET, OSTERVILLE Owner: VILLAGE COTTAGE ASSOC. Date of Inspection: DECEMBER 15, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to no groundwater 20 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions X Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: GROUNDWATER DEPTH TAKEN OFF INSPECTION REPORT ON FILE BARNSTABLE HEALTH DEPT.1996 revised 9/2/98 11 I _ / CERTIFIED SEPTIC SYSTEM REPORT LOCATION THE VILLAGE AT COTACHESET BUILDING B . 716 MAIN ST . OSTERVILLE, MA 02655 MAP 141 PARCEL 037 PREPARED FOR 10 MR. ANDREW WITTERs a FIRST PROPERTY MANAGEMENT ao 832 MAIN ST. 14N �j OSTERVILLE, MA 02655 ,1 6, 0 BUYERi, NONE AT THIS TIME PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 f Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WU=F.Weld Trudy Core GOAMW Sw•�+Y Argeo Paul Cailucel !?avid. S s LL 0OMM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION e. 9 Property Address N6 A-71.1%41 s T, Address of Owner. Dace of Itrspeotion: //1 Y (If different) Al�,!///G�`t X�j Name of Inspector. 3,1. AV'09iy Company Name.Address and Telephone Number. Aq l?Q/( asp C251wU/GL.rrC �i9 0�1Cs s CERTIFICATION STATEMENT 77eF'/5'7;L I certify that I have personally insoecsed the sewage disposal system at this address and that the infot-nation reported below is t-ue. acmtrate and complete as of the time of inspection. The inspecion was performed based on my training and experience in the proper function and m,flintannnra of ca{ite sewage disposal systems. The sy—m: . -L.lF asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Sipatuve: 2�1 Date: f� 7 The System laspe=r shall submit a copy of this inspecion report to the Approving Authority within thirty(30)days of completing this inspedion. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspe=r and the system owner shall submit the report to the appropriate z*&ual office of the Department of Environmental Protection. Tbs original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Cbw7&o 3oOR,C,or D: Al SYSTEM PASSES: AST `� I ha.e mot found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any farhu+criteria not evaluated are indicated below. Bl SYSTEM CONDTPIONALLY PASSES: One or more system components need to be replaced or repaired. The system.upon completion of the replacement or repair,paves Indicate yr;m,or not determined(Y, N, or ND). Describe basis of determination in all instances. If'not determined',explain why not) _ The septic tank is metal. cracked. strut- lly unsound, shows substantial infiltration or ezfiltr ation. or tank failure is i—rainent. The rstem will pans ::spect:on -S.he existing septic can's is replaced with a,onforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 ��Rr��►I �,�i One VAntar Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • T•lephone(617)292-5500 `l vnm.e on a.etie,.a Vlpe. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 4U/L,O/.vG B Properh'Addra.c Omer. fv Date of Inspection: Cbsck if the following have been done: ZPumPing information was requested of the owner. occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inapeccion. _ZAs built plans have been obtained and examined. Note if they are not available with N/A. _The facility or dwelling was inspected for signs of sewage back-up. /9.e-a✓ Sv�v,Gyci,Q_ 1,,'Ilhe system does not receive non-sanitary or industrial waste flow he site was inspected for signs of breakout. i� t/All system components,.gecluding the Soil Absorption. System. have been located on the site. The septic tank manholes were uncovered opened. and the interior of the septic tank was inspec-ed for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. _!fThs size and location of the Soil Absorption System on the site has been determined based on eatting information or •PPr�+ted by non-intrusive methods. fhe facility owner(and occupants. if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �6viG.oiv� Q Property Address Owner. �� //�5 T `'.'{'G�i�;2T Ar 7- Date of Inspection: : Z C/7 FLAW CONDITIONS RESIDENTIAL• Design flow:__----pllons Ni— of bedrooms: Number of tsrnnt residents: O Garbage grinder(yes or no):_ Laundry ooanstrsd to system(yes or no):— Seasonal we(yes or no):�S Water meter readings, if available: Last date of ootxpancy: _COMMERCIALANDUSTRIAL- Zype of r► hH.-hine"t. Design flow: - *llons/day, Grease trap present: (yes or ao)_ Industrial Waste Holding Tank present: (yes or no)— Nonaanitary waste discharged to the Title 5 system: (yes or-no)_ Water mew.readings, if available: Last date of otxatpaacy: OTHER:(Deembe) Last date of o=gxu T. GENERAL INFOIL ATION' PUMP f information: OPT �Sym m pumped as part of inspection: (yes or no) If yes,-hu— pumped: gallons Rasson for pumping: TYPE OF SYSTEM So*tankdistzrbution box/soil absorption system eyrgle oeaspool Overflow caaspool MmM system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components. date installed(if known) and source of information: p�1-1 /3Y S vA'v�yv2 Sewage odors detected when&riving at the site: tyes or not 1 p (revised 11/03/95) 5 r i SUBSURFACE SEWAGE DISP09AL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address* '2/L Owner. Jv f'i�sT f%?©�, 2j'Y Al 15"�1,16Z A;e e svT Date of Inspection: SEPPIC TANK: (beats an sita plan) r Depth b@6- grade:� Mzt ial of construction: veoncete_metal_FRP—other(explain) DW=xi ace: G'Y" Sbjdp depth: L3 Dist,aa from top of sludge to bottom of outlet tee or baffle: 45- Strom thicimess:_'n y Dktaaa from top of scum to top of outlet tee or haffle:/_ Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baflles, depth of liquid level in relation to outlet invert, rt:ucural integrity, evidence of LalCage. etc.) .T e alt-AT TL'E /5 39 /�fc L��w lH� /= �.�w Liy,� .4.vo THE ofG%i rXR /S ti'B QI foul i N,t fG<'c✓ GivE, /�pGyfi.�id,.o T, " T&' T/a'�5 /�,� c uT a,�� 7'11 car/�Y�i /fAs 'e GREASE TRAP:_ (bate an sits plan) Depth bebw grade: Material of ooasexvrion: _concrete_metal_FRP _othenezplain Dimensions: Scam thir�sss: Distance from top of scum to top of outlet tee or baffle: Distance from.bottom of scum to bottom of outlet tee or baffle: Comments: (rowmmendatioa for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relaton to outlet invert. structural mtagrity, evidence of leakage, ow.) (revised 11/03/95) 6 V' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addres.: ]j(o e,,5,7�',ZG-�Gc /Z Owner. 90 j,�iQsi f'�'o.���1 y /ti/9Ci�Gi��E.v 7- Date of Inspection: 11 f t16/S f97 TIGHT OR HOLDING TANK:_ (loots on die plan) Depth ba1awpads: Material of ooaservdion:_concrete_metal_FRP _other(explain) Dimensions: c paciv ¢allons Design flow: sailonsiday Alum level Comments: . (condition of inlet tee,condition of alarm and float switches.etc.) DISTRIBUTION BOX:_--_ (loesto on site plan) Depth of liquid level above outlet invert:" 1> Cots: � (note if level and distribution is equal, evidence��lids scat-lover, evidence of leakage into or out of box, etc.) !` /J /li9l dr/ i" Ps°' - 1 F_ !/.LIE'— ro 666E S 'AX T Af 11s L at riy F ow Li 7/t vr�r s .ra G 3 v�r o oci.S 4 PUMP CHAMBER. _- (k acs on sibs plan) pwops in working ordar.(yea or no) Comments: ( s mood;hm of pump chamber,condition of pumps and aPPursenances. ) no 7 (revised 11/03/95) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION•(Coutinued) J3LVG � Propel'Address 7%G f!/�� 6 i CPs/-Z e t-/G 4 X l Date of InapeoUov- y-4" SOIL ABSORPTION SYSTEM (SAS):_✓ Uoats an she P1aa.if Posnbls;szcnvation not required, but may be appmzimated by non-intrusive methods) If not detarmiasd to be Present, explain: Type: Inching pits, number. hachmg chambers, number_. 8 Ohm, number: Lsehiag trenches, number,length: Leching fields, number,dimensions: *meow Carspool, number. Camments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatioa-etc,) 10, CESSPOOLS: (locate an site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of nun layer: Dimensions of oaespooL- Materials of construction. Inds ti—at patmid-ate.. kdow(oaaspooi must be pumped as part of inspection) Comments:(note Condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation,etc.) PSIVY:_ (bats as sits plan) Muarmb Dimensions: Depth of solids: Ca®msots(note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc,) (rein sed 11/03/95) 8 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) �v'iGo�,r�G 8 Prop"Adddre.c Owner. ,//lS /��O/�.rc-/l Date of Iaspeation: SKETCH OF SEWAGE DISPOSAL SYSTEM: inehrde ties to at Last two permanent references landmarks or benchmarks locate all wells within 100' (3 1 O Q it i i l � A uo 13 6 . � 1 a P3 DEPTH TO GROUNDWATER i Depth to po®dwour.. t' feet modkod of daearmiaetiaa or appr==tion: d 19` THr -'2 ? (revised 11/03/95) 9 •, 1�oi�G ,� TOWN OF BARNSTABLE(,SEWAGE LOCA1':-_:V 7l/P /yi��i✓ �% �(,nd 5 # AT VW:,AGE ASSESSOR'S MAP & LOT 'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3 ,o/Ts (size) i2' o6 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility y 3a 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 leachin ffaaa iility) Feet Furnished by X 7�� io 611 1051 3 vTA �-Sc G and0'STOWN OF BARNSTABLE " LOCATION -71& M4J-1 ISUJLJIWI Q SEWAGE # VILLAGE 0 5-rer o ASS SSOR S MAP&'LOT INSTALLER'S.NAME&PHONE NO. SEPTIC TANK CAPACITY LL LEACHING FACILITY: (type) 3 P. TS (size) NO.OF BEDROOMS BUILDER OR OWNER C 07 LheSe?' COh 4 4-r-- PERMTTDATE: 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 leachin facility) �-�- Feet Furnished by,1—4 S9 C106 2 a; �0/� o so a L Ay Aa- yg 43 3 A 3" a$ 83- IQ 02 A4- y � . ' C oTAG�c Sc` ' G an TOWN OF BARNSTABLE LOCATION �I�_ InAm ST SEWAGE # Y I� VILLAGE ST�e i ASSESSORS MAP & LOT Ay/ d337 i INSTALLER'S NAME.&PHONE NO. I SEPTIC TANK CAPACITYllL(7 (( LEACHING FACILITY: (type) ! (size) O�Lb NO. OF BED OOMS . Ze BUII.DER OWNER CD7r ._ S� Gb �. . / 7_' C�4 PERMITDA� COMPLIANCE DATE: . Separation Distance Between the: Maximu mm Adjusted Groundwater Table to the Bottom* of Leaching Facility, Feet Private Water Supply Well and Leaching Facility Facili I. (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 leachin facility) Furnished by��SOCGTt a:, � FOi � Feet I I (3�1 1310 80 i. 6y Ay 1 At- al- 3 Aa- Y a a- �+3 A 3 a Atl- S L . t , w l a TOWN OF BARNSTABLE LOCATION �� r��,i✓ s% SEWAGE # i ASSESSOR'S MAP &.LOTIN R'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING.FACILITY: (type) 3 i'TS. (size) �6 NO.OF BEDROOMS i BUILDER OR;OWNER, ftRMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 5'3a 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 leachinn fa iility) Feet Furnished by . l r . a ;? I S EW A G E PERMIT -N0. LO C A.T. ION VILLAGE -' I N S T A LLER'S NAME i,. ADDRESS Co I fin S UILDER OR OWNER DATE PERMIT 1S.3UED DATE COMPLIANCE ISSUED - ig �g� . I Zq Zti 37 99 1