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HomeMy WebLinkAbout0727 MAIN STREET (OST.) - Health (4) 2 �by �-F Ma'in Street (Ost.) Osterville P °1jtcQVi F a.•.e__ �e/�v: A =.141 013 —h'Q s» tp— 41-5j� f a , 0 k.� u �v e r l n e m o ° , ' - •. 4 r e N � .. n <. it Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. E, F,J,1 Property Address wtanno Knolfs Condominiums Ownef OwneesName eftmunim mQuired for�y Ostervilie DNA 02655 5-16-12 page. Cf rown State Zip Code slate of Inspection inspection results must be submitted on this form. Inspection formes may not be altered in any way.Please see completeness checklist at the end of the form. fl"out� A. General Infortnation � ale � 1. Inspe r. = JAMES wtsor-d4 not James D. Sears 'o VSe the yet= SEARS •-� lacy. Name of Inspector Capewide Enterphses,LLC �i��lC�RTIF���I'•'��: a� CO(r►peny Mdtr�e '�,�5 l'J SY�'_ \` 153 Commercial Street Comparry Address -....- Ma 02649 �� Stft Zip C.Oa 50&477-W77 S1523 Tedepl a e Nunber L.Eaense NUxnber B. Cer#ificadon .J 1 certify that t have personalty 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 dsposal systems. l am a DEP approved system i pursuant to Sew 15-W of Title 5(310 CWR 15.000).The system: ® Passes j] Condftrmfly Passes C1 Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-16-12 s Skjrsature pate 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 flour of 90,000 gpd or greater,the inspector and fire system owns'r shall submit the report to the appropriate regional office of the DEP The originr,i,�l should be sent to the system owner and copies sent to the buyer, if applicable,and.the approvi �uthority. ""This report only describes conditions at the time of inspection and under the editions 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(trse7, WIG' - � I! Z1101 ..3� 1 4 k 1` 0 01 75nzs-91nfl Tim 5 0�31 fOtfa:S�ss�re t Syat�m-papa�rft 1T 3GI 0l� �i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. E. F.J,1 Property Address Wranno Knolls Condominiums Owner Owner's name infaffn for ati requiredf f every Ostelville MA 02655 5-15-12 per, atymown State Zip Code Date of inspection B. Celf fication (cont) Inspection Summary Check A,B,C,D or E I always complete all of Section D Aj System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15,304 exist Any failure criteria not evaluated are indicated below. Comments: B) System Conditiartatty Passes: ❑ One or more system components as described in the°Cnrxfitional Pass"section need to be replaced or repaired,The system, upon completion of the replacement or repair,as apprt vesi Qy the Board of Heaftk 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 riot)is structuraRy unsound,exhibits substantial infiltration or eufiitration or tank failure is imminent. System will pass insertion if the Ong tank is replaced with a complyM 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): ism•1 tPrrt Tft 50ftW kopeebm Fria%barf =Sawaps UWpWd System'Page 2 of 17 I Commonwealth of Mlassachusetts Title 5 Official Inspection Form Subsurface Sewage ENspwal System Form-Not for Voluntary Assessments 727 Main Strieet Bldg. E F J 1 Property Address - Wianno Knolls Condominiums ckvner owner's Name Information is required for e+ery Osterville AAA 02655 5-16-12 page. Chyrrown State Zip Code Date of inspection B. Certification (cons) B) System Conditionally Passes(coat): ❑ Observation of sewage backup or break out or high static water level in the distribution box clue to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass-inspectkm if(with approval of Board of Health): 0 broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obsu action is removed ❑ Y ❑ N ❑ ND(Explain ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explatin 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 OWs)are replaced ❑ Y ❑ N ❑ NO(Explain below)- ❑ obstruction is removed ❑ Y Q N ❑ N©(Explain tom): 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 heai;hr safety and the environment: ❑ Cesspool or privy is within 50 feet of a siurface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh N;me•Tina Tft5MWtopnf±a,mom%ftwf=SOON@ OWPOW&JOWn•I'Ve8orTF CommonweaM of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Stem Form -Not for Voluntary Assessments 727 Main Street Bldg.. E. F,J,1 Property Address --- Wianno Knoifs Condominiums owner Ow des Name hftslud is requo0stelvklle MA 02666 5-16-12 PW. cwery cdyirown State Zip Code Dale of lnspedon B. Cer cation (coat) 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 heap, 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 wi fm a Zone 1 of a public water supply- [I The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply weft. ❑ 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"". ittttad used to determine distance: *�This system passes it the well water analysis, performed at a DEP cefified laboratory, for fecal cofiform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 pprn, 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 cornpnnent due to overfxded or egged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than T bekm invert or available volurne is less than%day flow Oft.lino T%&5 Of kiM I spocbm Force SubuntaM Swrage sysiam-POO*4 at TT Commonwealth of Massachusetts tts Title 5 Official Inspection Form Subsurface Sewage E}isposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. E. F,J,1 Property Address Wianno Knolls Condominiums Otvraer ownw5 ttart:e required for every orf Osterviffe MA 02655 5-16-12 per, city rro" atate 23p Code Date of lnspecw B. Certification (coat.) Yes No ❑ Required puMMg more t#tan 4 t;y in the last year MOT due to dogged or obstructed piWs).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 fleet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone I of a public welf. ❑ 9 Any portion of a cesspool or privy is within 60 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 liallmnatory,for fecal cotfiform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Sass than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and cdudn of custody racist be attached to this forrn-j ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system faits.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 erect 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 ddrddng water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA) or a mapped Zone If 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 wed a signi artt threat under Seems E or failed under Sectim D shalt upgrade the system in accordance with 310 CUR 15.304. The system owner should contact the appropriate regional office of the Department >5m•t f/So '11%S Of W kWacbm form%ftwfwa SmW DwpoW Sysion-Pope 5 of 17 Commonwealth of Massachusetts Tine 5 Official inspection Form Sufturfac a Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street MR. E, F, J,1 Property Address Wlanno Knolls Condominiums _ � Ownes's tine Ostervlile MA 02655 5-16-12 page. cRyamn State Zip Code Date of bvoerYmn C. Checklist Check if the following have been done.You must indicate°yes°or°no"as to each of the following: Yes No 0 ❑ 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 kne volumes of water been mtmduoed to the system mm*or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ❑ Was the fac"ifity or dwelling inspected for signs of sewage back up? (D ❑ 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? ER ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposaf systems? The size and location of the Soil Absorpbon System(SAS)on the site has been determined based on.- Existing infomration. For example,a plan at the Board of Health. ❑ Determined in the fieW(if any of the failure a itei related to lit C is at issue approximation of distance is unacceptable)(310 CMR 15.302(S)j D. System Information Residential Flow Cond-k s: Number of bedrooms(design): 16 Number of bedrooms(actual): 16 DESIGN flow based on 310 CMR 15.203(for example. 110 gpd x#of bedrooms): 1760 Lsins•�1r1Q TW 50MCW VOW' Wn Fong hOaafte Serape UAPCqW sfftm•papa 6 ar77 Commonwealth of Massachusetts Tine 5 Official Inspection Foy Subsurface Sewage Dyad System Form-Not for Voluntary Assessments 727 Main Street Bldg E F J,1 Property Address b'1iwtno Knoils Condominiums _ owrars Name fS mqukedfbr&jeq Ostenrille MA 02655 5-16-12 fie. cityfrown State Zip Cade Date of lmpecwn D. System information ""he is a 2500 Gat Precast tank D Sox and four pits H -20 Number of current residents: Does residence have a garbage grindeO ❑ Yes �. NO Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes El No Water teeter readings.if avaRable(last 2 Years usage(gpd)): MA Detail. sump pump? ❑ Yes ❑c No Last daLe of Present fl��i- t� ConunercialRncdustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203). Gaels per day(am) 13asis of design flow(seats/personslsq-it.,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: esau•s ins �s oar rnpsr�m,rwnr St�a►aoe Se+nspe s •I�IDgm'�i7 r- Commonwreaith of MassachuseM Tide 5 Official Inspection Form Subsurface Sewage Disposef Systm Form-Not for Voluntary Assessments e 727 Main Street Bldg_ E,F, J,I PrWeAy Address Wenno Knofis Cor uominia= Owner` QWrW$Nam every Osterviiie MA 02655 5-16-12 page, Cityrraw State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): Geteeral lrrfornmHon Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No. If yes,volume pumped: How was quantity pumped determined? Reason for pumping_ Type of SystNW-- ® Septic tank, disbibution box, sort absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy [l Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ tnnovativelAttemative technology_Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 1/A system by system operator under contrail ❑ Tight tank Attach a copy of the DEP approval. ❑ Omer(describe): tSri-:tnc Tale 5 t Faro:S.Gect�sSc,�e -PapsB •_ Commonweahtr of Massachusetts Title 5 Official Inspection Form %bawhum S www Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg_ E. F,J,1 Property Address Wianno Knolis Condcmrnrums owrwr owners Nant,e hiformaW+As—ny 0stervlfe MA 02655 5-16-12 page. ckyrrown state Zip Code Date of lespedion D. System Information (cost.) Approximate age of all components,date intake(if known)and source of information: 1961 New D Box 5-12 Were sewage odors detected when arriving at the site? ❑ Yes No Butld'ing Sewer(locate an site plan): Depth below grade: 4' few Material of construction: ❑cast iron . 0 40 PVC ❑other(explain): Distance from private water supply well or suction fine: Comments(on condition of joints, venting,evidence of leakage.etc.): Pipes is 4"pvc sch 40 Septic Tank(locate on site plan): Depth below grade- Material of construction: Cl concrete ❑metal ❑fiberglass ❑polyethylene ❑other(e)plaln) If tank is metal, list age: Yaws is age confirmed by a Certificate of Compliance?(attach a copy of certifnmte) ❑ Yes ❑ No Dimensions: 2500 galions Sludge depth: 2" tSsa-t tHD Titles OE ' trra.6% Far:s:twum swage syshn-Rix 6 of t: Commonwealth of Massachuw is mom MM Title 5 Official Inspection Form Subsurface Sewage Disposal S"Wm Farm-Not for Voluntary Agents 727 Main Street Sldct. E, F,J,'l Property Address Wtanno Knolls Condominiums Owner ownees Nor m me is for Osterviiie MA 02853 5-16-!2 reqviftdemy per, Chya wn State Dp Cade Dam of lnaoecdon D. System information (coat) Septic tank(cont) Distance from top of sludge to bottom of outlet bee or baff3e NA -- Scum thickness 2" Dlstan:ftum,top of scum to top of outer fee or baffle NA Distance from bottom of scum to bottorn of outlet tee or tame NA How were dimensions determined? Tape Plan Past Deport Cwr:rnen s(on pumping and outet tee or baft cam.striuctural integrity, ilguid levers as related to outlet invert,evidence of leakage,etc.); Yearly pumping, tank at 3`below grade w/steel covers at grade, No sign of feakage or over ioa�g Grease Trap(locate on site plan): Depth below grader �t Material of construction: 0 co=ets ❑metal ❑fibergtass Lam.. polyethylene Q 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 bee or baffle Date of last!um-0,rig- Date '.Scs-IIng TfSeS Wsp-JM.FaF:Ssssfaca$-We ram, saSy—,FVWWC9tT Commonwealth of Massachtseft Title 5 Official Inspection Form Sabsudace Sewsp Disposal System Form-Not for Vaiuntary Assessments 727 Main Street Bldg. E F.J 1 Property Address Wrianno Molts Cmdorninkimis 9 Osterville MA 02855 5-16-12 pence- for C4rTown State Zip Code Date of inspection 0. system information (cont.) Comments(oar pumping recommendatians, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.).- Tight or H Tank(tank must be pumped at tin of ice)(locate on site p1m): Depth belays grade: Niaalerial of construction: ❑concrete D metal ❑fiberglass ❑po iysthyletie ❑other(explain): Dimensions: Capacity: Design Flow. gam per day Alarm present: 0 Yes No Alarm level: - Alarm in Acing order: ❑ Yes El No, Fiats of last pumping: DWIS Comments(condition of alarm and float switches, etc.): Attach copy of currei pumper conwact(recluired)_ is copy aft acted? 0 Yes 0 No -1�wrJ Tft 5 iayaz=F.= S.Ss iry�s-arse Dapxse Sjsfsn-ftV&14 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Stfturface Sewage Disposal System Form-Not for Voluntary Assessments 727 fain Street Bldg. E, F..i,1 Property Address Wtanno Knoffs Condominiums mqtAmd for emy Osterville UA 02655 5-16-12 page. cayrrown state zip code Date of Impaction D. System Information (coot_) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outset invert Comments(note if box.is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.). D Box is new 542, Box is N-20 w f Steel cover at grade, ftwr tine's out Ptartp Chamber(locate on site plan): Pumps in worsting order. ❑ .Yes ❑ No Alarms in worming order. ® Yes p No Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Solt Absorption SysUm(SAS)(lie on site plan. ocavahan not requff": If SAS not located, explain why: t5ss•t!t�3 TdSe 5�asC 5�"nc:Eocar S'+•^�'-Ser�,e S��*�!Y a/7 CommonareaM of RMassachuseft Title 5 Official inspection Form Subst,da"SAm"Dkposa+Sysftm Form Not for voluntary Assessment 727 Main Street Bldg. E, F. J,t Property Address Wianno Knolls Condominiums _ owners Nmm for may, Ostemi{ie iA 02655 5-16-12 Paw_ cRYrrow:, stato T�p Code nete or irspx6ffl Q. system ill forma ion (eruct-) Type: ® teaching pits number. 4 D leaching chambers number. Q leaching galleries number_ Q leaching trenches number. length: ] leaching fields number, dimensions: Q overflow cesspool number: 0 itmovativefaltemative system Type/name of te�y. Con entss(note ciandition of soil, signs of h ftikm leM of poiding,damp-A caridkim O vegetation, etc.): Leaching is four H-20 Precast Pits Wt steel covers at grade, Pits are around 4'below grade, level inpits 2, at 3M-1 at Z and T at 4"level off due to old box in the past 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 sorids layer Depth of scum►layer Dimensions of cess" !Materials of oonst*t1Gt' n Indication of groundwater inflow 0 yes ❑ Elo tfim-t Ina Tfle 50 5=i Fam SL&Psb e 5 Disco"8ysam-Paps 13 of 17 Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg E, F, 3,1 Property Address Wianno Knolls Condominiums._ t)aares Cwnees N2nw Wymabw Is mqua-ed for Osterville MA 02655 5-16-12 �orr;ry.Page. Cityrrown State Zip Cade Dam of laspeaion D. System Information (coat.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Parry(locate on site ): Materials of construction: Dimensions Depth of solids Comments(ram condition of soil,signs of hydrauk fallurre,level of ponding,condition of vegetafion, ISaz•r tplfl TtlC 5 OliMM iYs::• PaW 14oft7 Collmonweaith of Massachusetts alum Title 5 Official inspection Fort Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street BldS. E. l=,Jj Property Address Vlfianno'K otls Condominiums kdbMUWM Is cequked for eveiy Osterville MA 02655 5-16-12 Cityfrm.m State Z10 Code Qate of Umpection D. system Information (coat.) 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 welts within 100 feet. Locate where public water supply enters the building.Check one of the loxes below: [} hand-sketch in the area below ® drawing attached separately I l i i e tno Tara 5 o �a �or�SarBeoa see sys�a•raga es tT No. I �I (�( Fee THE COMMONWEALTH OF MASSACHUSETTS�I Entered in computer: Yes PUBLIC H ALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS plicatI011 for I8�lD8aY *p8tP1I1 CO11stCU1rt1011 Prllltt Application for a Permit to ons t( ) Repair Upgrade( ) Abandon( ) ❑Complete System 2 Individual Components Location Address or I,ot o,, v� �{" Glv►ib L-�•f' Owner's Name,Address,and Te�No. /oVx � I Assessor's Map/Parcel i17 vQF ri �57 d E 5Z�F �27(f>a99 Installer's Name,Address,and Tel.No. S`Z,3_�1y77 77,, Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)Q@!P1 C .o -�bx Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date .5—`t—120 --- Application Approved by Date Application Disapproved by Date for the following reasons Permit No. P s ' Date Issued /L No.9C I 4 - l J (a I Fee i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i PUBLIC H ALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 'a — plication for ;Disposal *pstrm Construction Vermit Application for a Permit to Co t( ) Repair(�Upgrade( ) Abandon( ), ❑Complete System M�Individual Components Location Address ppr of o.. �� U A il5 4F Owner's Name,Address, nd .Te No. vle— UJ a Assessor'sMapParcel T S '-Yoh o;Z99 f Installer's Name,Address,and Tel.No. t> . - 77 n Designer's Name,Address,.and Tel.No. ' �n� rtSQSt �r Type of Building: t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Person - Showers( ) Cafeteria( ) - !"~w "`Other"Eiztaresr. t I ' .> Design Flow(min.required) gp Design flow provided gpd i .� Plan Date ! ber of sheets Revision Date g. Title / Size of Septic Tank Type of S.A.S. Description of Soil _✓d , a r ( .,, I i Nature of Repairs or Alterations Answer when applicable) [�cz A4e'i l X P ( PP ) `�. l D O t ({I t Date last inspected: x � Agreement: ,• _- ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in / I accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed A D to Y� `�.-A licationA Approved Date 5- PP PP k 'Application Disapproved by Date j for the following reasons i Permit No. ;20 1 P Date Issued --------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS CPrtIfItAtP of.COltYtltIaTCLP THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V) Upgraded( ) Abandoned( )by C1�S-�S at 7� ' ' lay'" �`"r� S 1 6- "``� as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ePO 1.2 l q 5 dated Installer aw(�o^4Z-G�tO`x 'nse5; i - Designer #bedrooms;, Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as es`igned. N, Date � Inspector y ------------ - -- No. Fee �C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,.MASSACHUSETTS Misposat *pstrm Construction Vermit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon.( ) System located at 7�CO 1 e �'15�, Ut^ L r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit Date � (y- Approved by r 1 * I a r I 'J { i 1 `gam Jw t ! I Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 727 Main St. BIdg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out �I ��� forms on the computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 Cityrrown State Zip Code (508)428-4028 S14454 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 15340 4# Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails': r ua� .ram ❑ Needs Further Evaluation by the Local Approving Authority cry co 9-/Z� 4/16/2009 ul 1173 Insp tor's SiVK.Yure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should�be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M °L 727 Main St. Bldg.E,F,J1 ' Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osteryille Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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): t t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 . Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 727 Main St. Bldg.E,F,J 1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El Elthe 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. CitylTown 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): 16 Number of bedrooms (actual): 16 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1760 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 2500 gallon septic tank,distribution box and four leaching pits. Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Sep.Meters 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4/16/2009 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: L15,..•09/08 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 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 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: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main St. Bldg.E,F,J 1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville Ma. 02655 4/16/2009 required for every page. City[T'own State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1981 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: 104 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 3'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2500 gallon Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. City/Town 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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•09/08 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 4M , 727 Main St. BIdg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 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 727 Main St*Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Cisteryllle Ma. 02655 4/16/2009 every 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has four outlet laterals.Distribution is equal after installing speed Ievelers.No evidence of solids carryover.No evidence of leakage into or out of box. 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•09/08 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 a 9 p Y rY 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 4 ❑ 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.): Sandy dry soil.No signs of hydraulic failure.2 pits were 3/4 full and 2 were dry.lnstalled speed levelers to equal distribution. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 y , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Vlewer Custom Map Abutters Map Size Zoom Out 1,111 M j jIn y K R,a x� a o. O ,6 rZ , 3 €� � 9 � kC w .uj n x. T q Q 20 Fe t ........................ .. .......... Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER r,—,,inhf 9fV1F_0nnA Tnum of 11-0.hlc NAA All rinhfc rocnv; http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertylD=l 4101300A&... 4/28/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Fort W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 6.4'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: 1981 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • i Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 727 Main St. Bldg.E,F,J1 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for Osterville Ma. 02655 4/16/2009 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t -� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - �� DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET WEST YARMOUTH, MA �?8 508-775-2800 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 141 PAR 013 PROPERTY ADDRESS: 727 MAIN STREET, OSTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: JANUARY 18, 2000 WIANNO KNOLL CONDO NAME OF INSPECTOR : JULY 20, 2006 BUILDING F 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 c INSPECTORS SIGNATURE: a/� DATE: JULY 24,2006 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. NOTES AND COMMENTS: BL`D"G:F—SYSTEM ALSO SERVES BLDG.E- m SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME t OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. — - ,- a i revised 9/2/98 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIVICATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO, BUILDING F Date of Inspection: JULY 20, 2006 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: X 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 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 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 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING F Date of Inspection: JULY 20,2006 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 15.303 (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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE w Owner: WIANNO KNOLL CONDO-BUILDING F Date of Inspection: JULY 20,2006 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in pits is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 II 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 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST, Property Address: 727 MAIN STREET, OSTERVILLE ' Owner: WIANNO KNOLL CONDO-BLDG.F Date of Inspection: JULY 20,2006 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 owner,occupant,or 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. s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING F Date of Inspection: JULY 20, 2006 FLOW CONDITIONS RESIDENTIAL: Design flow: 1760 g.p.d./bedroom for S.A.S. Number of bedrooms(design) - 16 Number of bedrooms(actual): 16. Total DESIGN flow N/A Number of current residents: N/A Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): N/A Sump Pump(yes or no): NO Last date of occupancy: PRESENT COM M ERCIAUINDUSTRIAL: 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: NOTE:MAINTENACE PUMP AFTER INSPECTION. ' 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 X Shared system(yes or no)(if yes,attach previous inspection records,if any)BLDG E,F&OFFICE. I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of D E P Approval Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 1984 Sewage odors detected when arriving at the site:(yes or no) NO r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING F Date of Inspection: .DULY 20,2006 BUILDING SEWER: (Locate on site plan) Depth below grade: ' Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: X (Locate on site plan) _ Depth below grade: 45 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: 2,500-GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 68" 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: 11" How dimensions were determined PLAN&TAPE 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.) MAIN TANK AT WORKING LEVELTWO INLET TEE'S OUTLET BAFFLE,BOTH COVERS STEEL AT GRADE. _ NO SIGN OFF OVER LOADING OR LEAKAGE. 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 baffler 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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET Owner: WIANNO KNOLL CONDO-BUILDINGF Date of Inspection: JULY 20, 2006 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: X (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,) D-BOX IS 2'X 2'40"BELOW GRADE.INE LINE IN FOUR LINES OUT. BOX IS SOLID WITH STEEL COVER AT GRADE. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. 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.) • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING F Date of Inspection: JULY 20,2006 a SOIL ABSORPTION SYSTEM (SAS): X (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: 4 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.) LEACHING IS FOUR PRE CAST PITS,ALL PITS HAVE STEEL COVERS AT GRADE. 18"TO 22"WATER IN PITS. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. 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. g 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) s Materials of construction: _ Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING F Date of Inspection: JULY 20,2006 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) SEE ATTACHED PLAN. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING F Date of Inspection: JULY 20, 2006 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 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record X Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers, Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: PLAN ON FILE AT BOARD OF HEALTH, 12' NO GROUNDWATER—SITE HIGH. � I I L ' 8 �T7- #zPN J� p I of11,Zi h... . �• I26.40' AF • ` • �/ � `//�___) - I , �1 �. i L��� r•��f^ • �.;•� .•ram �-y }. `/ �.,_�-� ����—"'__ .._._- _..__. _ �•;" �i :: .f �_ 4 '(. 1, ,y,� J..L..J psi�� ' ; 'lCr .� ��J..���['"/ :� ��> �ivtr✓•. i,t`� fir,-.�-.:{�, ,f- „'�►�`' /_ �- � ...` ' \ t �.��� '�7d.%�� ���, .cam-f�� �'.'". �.ia�• ~ .; ♦'- r�. rJ �' lfre 1'-.!�-;�� ..1• ::-G.. j�r'�1 _ �!'r^�"r:iM' y:>', =,- i?' 1 ra - y •a /.y.�: - i'')r:,n:: •C��S ��Tf•.i t h';'r_t �.t+ .,r�-�.�••.rf�-:�-• -.,e..y� �'�].P �' ,t� .Iv��'� .. _ � _' .'_'�'�� —w.."'1=T, .``._„r rM :.� •3:.,"i'^tic' - Jr�.'y t! v�akr �...r..?- - :�:1'a �•1 .sue.' \'� •14. �-�+�:..• .1*_$ a � - _ ___ •� .• - •• •..f'.' t, �. .�: `.�;,r lit . t �.1 . 4. COMMONWEALTH OF MASSACHUSETTS z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION °'oqM SVe�� RECEIVED /� 350 MAIN STREET /�"� WEST YARMOUTH,MA NOV 18 2003 508-775-2800 TOWN OF BARNSTABLE TITLE 5 HEALTH CREPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 141 , PAR 013 Property Address: 727 MAIN STREET-BUILDING F OSTERVILLE,MA 02655 Owner's Name: WIANNO KNOLLS CONDOMINIUMS Owner's Address: 727 MAIN STREET OSTERVILLE,MA 02655 Date of Inspection OCTOBER 14,2003 Name'of Inspector:(please print) JAMES D.SEARS 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 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: 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 tot he buyer,if applicable,and the approving authority. Notes and Comments BUILDING F—SYSTEM ALSO SERVES BUILDING E ****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 1 Page 2 of I 1 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 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: T B. System Conditionally Passes: N/A ' 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 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: Title 5 Inspection Form 6/1'5/2000, 2 f Page 3 of 11 OFFICIAL INSPINSPECTION FT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 727 MAIN STREET—BUILDING F' OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 D. System Failure Criteria applicable to all systems: N/A 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 pits is less than 6"below invert or available volume is less than%day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service 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 is 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. Title 5 Inspection Form 6/15/2000 4 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART B . CHECKLIST Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 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)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)] ° A .n v_ .. { - .• r 3• a r. •A. r r e Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 4 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS . Date of Inspection: OCTOBER 14,2003 FLOW CONDITIONS .t - RESIDENTIAL r Number of Bedrooms(design): 16 Number of bedrooms(actual): 16 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms: 1760 Number of current residents: A N/A Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A _ •Sump Pump(yes or no) NO " Last date of occupancy: PRESENT . COMMERCIAL/INDUSTRIAL Type of establishment: m Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,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: A OTHER(describe): GENERAL INFORMATION Pumping Records., Source of information: —ANNUAL PUMPING 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. - a Overflow cesspool - Privy " ✓ Shared system(yes or no)(if yes,attach previous inspection records,if any) BUILDING E,F.AND OFFICE Innovative/Alternative technology: Attach a copy of the current operation and maintenance contract(to be _ obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no): NO .Title 5 Inspection Form 6/15/2000 6 f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 BUILDING SEWER(locate on site plan): N/A 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 onsite plan): ✓ Depth below grade: 45" 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: 2,500 GALLON PRE CAST Sludge depth: P, Distance from top of sludge to the bottom of outlet tee or baffle: 68" 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: 11" How were dimensions determined: PLAN AND TAPE Comments(on puinping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.TWO INLET TEES,OUTLET BAFFLE.BOTH COVERS STEEL AT GRADE.NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ./ (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.,): DISTRIBUTION BOX IS 2'x2',40"BELOW GRADE.ONE LINE IN,FOUR LINES OUT.BOX IS SOLID WITH STEEL COVER AT GRADE. NO SIGN OF OVERLOADING OR SOLID CARRYOVER. 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.): Title 5 Inspection Form 6/15/2000 8 I Page 9 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4 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 FOUR PRE CAST PITS.ALL PITS HAVE STEEL COVERS AT GRADE. 18"TO 20"WATER IN PITS.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: 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,eta) Title 5 Inspection Form 6/15/2000 9 s e l� Page,p of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET—BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS . Date of Inspection: OCTOBER 14,2003 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. Title 5 Inspection Form 6/15/2000 10 I Page 1 1 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET-BUILDING F OSTERVILLE,MA 02655 Owner: WIANNO KNOLLS CONDOMINIUMS Date of Inspection: OCTOBER 14,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to determine the high ground water elevation: J Obtained from system design plans on record-if checked,date of design plan reviewed: + J Observation 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: TEST HOLE ON PLAN.NO WATER 12'. AREA HIGH. <.�"4 Z L • Title 5 Inspection Form 6/15/2000 11 fib J. = = , COMMONWEALTH OF MASSACHUSE11"I'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL, PROTECTION ONE WINTER STREET, BOSTON MA 02.108 (617) 292-5500 t TRUDY COXF, 350 MAIN STREET Secretary ARGEO PAUL CELLUCCI WEST YARMOUTH, MA Governor & 508-775-2800 4 DAVID B. STRUHS 4 Comnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 141 PAR 013 PROPERTY ADDRESS: 727 MAIN STREET, OSTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: JANUARY 18, 2000 WIANNO KNOLL CONDO NAME OF INSPECTOR : JAMES D. SEARS BUILDING E I am a DEP approved system inspector pursuant to Section 15.340 of Title 9310 CMR.15.000) COMPANY NAME: A&B Canco = MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673: TELEPHONE NUMBER: j(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: DATE:, FEBRUARY.2,2000 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. NOTES AND COMMENTS: 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. NOTE: SYSTEM ALSO SERVES PART OF BUILDING F. ' n r ys O�ll� o0 ., rD revised 9/2/98 X r . 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIVICATION (continued) Property Address: 727 MAIN STREET,OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING E Date of Inspection: JANUARY 18,2000 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: X ' I have not found any information which indicates that the systems 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 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 willpass. 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 fi c revised 9%2/98 2 r ' , E e ,. l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: JANUARY 18,2000 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 15.303 (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 revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET,OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING E. Date of Inspection: JANUARY 18,2000 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%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 II 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. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING E Date of Inspection: JANUARY 18,2000 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 owner,occupant,or 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)[I5.302(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. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 727 MAIN STREET,OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: JANUARY 18,2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 880 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 8 Number of bedrooms(actual): 8 Total DESIGN flow N/A Number of current residents: N/A Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): . Sump Pump(yes or no): NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL: 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: YEARLY PUMPING 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: 1984, NEW D-BOX 1998 PERMIT#98-104 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET,OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: JANUARY 18,2000 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: X (Locate on site plan) Depth below grade: 45" 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: 2,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 67" Scum thickness: 2" 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: 101, How dimensions were determined TAPE AND PLAN 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,TOW INLET TEES.BOTH COVERS STEEL AT GRADE. GREASE TRAP: N/A t` (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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET,OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: . JANUARY 18,2000 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: X (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,) D-BOX IS 40"BELOW GRADE,24"X24",STEEL COVER AT GRADE. BOX IS NEW,ONE LINE IN,FOUR LINES OUT. BOX WAS REPLACED IN 1998 PERMIT#198-104. 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: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: JANUARY 18, 2000 SOIL ABSORPTION SYSTEM (SAS): X (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: 4 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.) FOUR(4)PRECAST PITS THREE(3)PITS IN BLACKTOP STEEL COVERS AT GRADE.TWO(2)PITS 3'WATER,ONE PIT 12"WATER,ONE PIT NOT RAISED OR OPENED,SHOWN ON PLAN,LOCATED UNDER BRICK WALKWAY. 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 r f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: JANUARY 18, 2000 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) SEE ATTACHED PLAN. -revised 9/2/98 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING E Date of Inspection: JANUARY 18, 2000 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 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: TEST HOLE ON PLAN, NO WATER AT 12'. revised 9/2/98 11