Loading...
HomeMy WebLinkAbout0727 MAIN STREET (OST.) - Health (6) !: 727 (BIg D) Main Street (Ost.) Osterville P y A = 141 013 } i. v e 04 0�3- 00A Commonwealth of Massachusetts - - : Title '5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main Street (Bldg D) u Property Address ; n Wia nno Knoll Condom iniums ay Owner Owner's Name + information is Osterville MA 02655 9-28-20 ' required for every - - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may hot be altered'in any ` way. Please see completeness checklist at the end of the form. ``�UUpIOF Important:When A. Inspector Information j / 13q filling out forms O: G on the computer, JAMES Ln use only the tab .lames D.SearsJ�- key to move your Name of Inspector cursor-do not Robert B.Our Co.1NC J •.L. 4r use the return - -- --- - - ke Company Name !F y 363 Whites Path Company Address South Yarmouth MA 02664 City/Town -----�-----T- -- State`'` ------_ Zip Code' _--- srmn 508-477-8877 _ S1623 " Telephone Number A ^� License Number B. Certification ', I certify that: I am a DEP-approved system inspector in full,compliance with Section 15.340 of Title 5 (310 CMR.15.000); I have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and.the inspection was performed based on my training and experience in the proper function and maintenance of on-site.sewage disposal systems. After conducting this inspection I have determined that the system: 1. Passes p. 2. ❑ Conditionally Passes* 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails _ 9-28-20 nspector's Signature Date The`system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has'a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 0, Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main Street(Bldg D Property Address Wianno Knoll Condominiums.______ - Owner Owner's Name — information is Osterville a MA 02655 _ 9-28-20 required for every --- .,---- -- equi City/Town state Zip Code Date of Inspection ` C. Inspection Summary Inspection Summary:,Complete 1,2, 3,`or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated_ below. Comments: ') 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): i t5insp.doc•rev.7/26!2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 l Commonwealth of Massachusetts �_-- ,p Title 5 Official Inspection Form �- 1> r I� Subsurface Sewage Disposal System Form'-" Not for Voluntary Assessments 727 Main Street(Bldg D) Pr Address Property Wianno Knoll Condominiums _ Owner Owner's Name information is Osterville MA 02655 9-28-20 required for every — --- - - page. City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational.,System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7l26i2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments eh ! 727 Main Street (Bldg D) _ u Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 9-28-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) - ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has'a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water-supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic 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 10,0 feet but 50 feet or more from a private water,supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form. �1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main Street(Bldg Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA' 02655 9-28-20 required for every - -- - page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (con t:j 4) System Failure Criteria Applicable to All Systems: (cont.) Yes ,' No Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® -or clogged SAS or cesspool El ® Liquid depth in is less than 6" below invert or available volume is less than '/2 day flow Pj T ® Required pumping more than 4 times in the last year NOT due to:clogged or, obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool.or privy is within 100 feet of a surface water supply or , tributary to a surface water supply. ❑ ® Any portion of a cesspool or,privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool'or privy is less than 100 feet but greater than 50 feet from a private.water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving-a;facility with a design flow of 2000 gpd- El 10;000 gpd. Ej 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 ownershould contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve.a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you,must indicate,either"yes" or"no"to each of'the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply, ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 L .� Commonwealth of Massachusetts :. Title 5 Official Inspection Form J �ii Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments < � 727 Main Street(Bldg D) Property Address P Y Wianno Knoll Condominiums Owner Owner's Name -- information is Osterville MA 02655 9-28-20 required for every - -- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont): If you have answered ".yes" to any.question in Section C.5 the system is considered a significant v threat, or answered "yes. to any question ln.Section CAabo e the large g system has failed. The owner or operator of any large system:considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMRFl5.304. The system owner should contact the-appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: I 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 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 breakout? ® ❑ Were all system components,,excluding the SAS, located on site? _ 0 ❑ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, - dimensions, depth of liquid, depth of.sludge and.depth of scum? Was the.facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location.of the Soil Absorption System(SAS) on the.site has been determined based.on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR'15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 L- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knoll Condominiums Owner Owner's Name information is 02655 9-28-20 required for every Osteryille _ MA _ page. City/Town State ZipCode Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms"(design): 8 'Number of-bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110.gpd z#of bedrooms): 880 Description: The system is a 2500 Gal. precast tank D box 4 pits: _ Unknown Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes Z No If yes, discharges to: - Is laundry on a separate sewage system? (Include laundry system inspectionEl` Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes Z No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� . Detail: _ Sump pump? ❑ Yes ® No Last date of occupancy: Present _ p Y, Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18 L Commonwealth of Massachusetts q Title 5 Official Inspection Form i�) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 727 Main Street (Bldg D) _ Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02855 9_28-20 required for every - - -------- — - -- page. City/Town State Zip Code Date of Inspection D. System Information (cont) 2. Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow(based.on 310 CMR 15.203):.. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): -- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: - Industrial wasteholding tank present? ❑- Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No. Water meter readings, if available:- Last date of occupancy/use:`. bate Other(describe below): 3. Pumping Records: Source of information: Yearly Pumpin g__ - Was system pumped as part of the inspection? ❑..Yes ® No If yes, volume pumped: . gallons --- How was quantity pumped determined? - - Reason for pumping: — ---- . t5insp.doc•rev:712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts - . Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form Not for Voluntary Assessments 727 Main Street Bld D)_ Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 9-28-20 required for every ----- — — -- — page. CityfTown State Zip Code bate of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP,approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 — P 9 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Piping is 4' Sch 40 PVC. t5insp.doc•rev.7126 2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 L Commonwealth of Massachusetts Title 5 Official: Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 727 Main Street(Bldg D) Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 . 9-28-20 required for every -- ----- -- - page. City/rown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 18,E Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) - If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a.copy of certificate). ❑ Yes ❑ No Dimensions: 2500 gal 21 Sludge depth: 48" Distance from top of sludge to bottom of outlet tee or baffle - _ 1a Scum thickness - 7" Distance from top'of scum to°top of outlet tee or baffle z 1411 Distance-from bottom of scum to bottom of outlet tee or baffle -- How were dimensions determined? Plan -Tape .Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc:): Tank at working level. 2 inlet tees. Outlet Tee inlet steel cover at grade.Out cover stee. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -. 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lz 727 Main Street(Bldg D) _ Property Address Wianno Knoll Condominiums _ Owner Owner's Name information is Ostervllle MA 02655 9-28-20 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information�(cont.) 7. -Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass- ❑ polyethylene �❑ other(explain): Dimensions: Scum thickness - Distance from top of scum to top of outlet tee or baffle — ---- Distance from bottom of scum to bottom of outlet tee or baffle' -- Date of last pumping: Date - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grader — — Material of construction: . x ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- -- Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 L Commonwealth of Massachusetts ,IP Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , r t `C V % 727 Main Street(Bldg D) Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA' 02655 9-28-20 _ :required for every — page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 8. Tight or Holding Tank(cont.) Alarm present: : ❑ Yes ❑ No Alarm level: — - Alarm in working order: ❑ -Yes ., _❑ No Date of last"pumping: Date Comments-(condition of alarm and float switches, etc:): Al "Attach copy of current pumping contract(required). Is copy,attached? ❑ Yes ❑ No. 9. Distribution Box (if present.must be opened) (locate on site plan): Depth of liquid,level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of"solids carryover, any evidence of leakage into or out of box, etc.): D Box,is clean and.solid. 22" Below grade with 18"cement cover 4" below grade.4 lines out no sign. of over loadinaor solid carry over. t5insp.doc•rev.7/26i2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts w Title '5 Official Inspection Form tiI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main Street 13ld ( 9 D) Property Address t Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 9-28-20 required for every _-�-- ----- ----- ------ ---___-- page. City/Town State Zip Code Date.of Inspection D. System Information,(cont) 10. Pump Chamber(locate on site plan): Pumps in working.order: ❑ Yes ❑ No* III Alarms in working order: ❑ Yes ❑ No* . Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS).(locate on site plan, excavation not required): If SAS not located, explain why:. Type: ® leaching pits 4 number: ❑ Teaching chambers number: El leaching.galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: f ❑ innovative/alternative system Type/name of technology: - - t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 L r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System-Form-Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 9-28-20 required for every — page. City/Town State Zip Code Date of Inspection D. System l`nformation (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs.of hydraulic failure, level of.ponding, damp soil, condition of vegetation, etc.): Leaching is 4 precast pits with steel covers at grade. Pit's 4-5-7 1'water. Pit 6 water at 5' below inlet. t t " 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ----- Depth -top of liquid to inlet invert Depth of solids layer' Depth of.scurn layer - Dimensions of cesspool ---- - — ---- Materials of construction -=---=--- r Indication of,groundwater inflow ❑ Yes El No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): k t5insp.0oc•rev.7/26/201b Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r r I Commonwealth of Massachusetts --: - ` Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 9-28-20 required for every - — ------- --- - - page. City/Town State Zip Code Date of Inspection D. System Information Cont. 13. Privy (locate on site plan); Materials of construction: -- . Dimensions Depth of solids — - — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 - L I ' Commonwealth of Massachusetts Title 5 Official Inspection Form R ���� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments V � 727 Main Street (Bldg D) " Property Address Wianno Knoll Condominiums Owner Owner's Name information is Osterville MA 02655 9-28-20 _ required for every --page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal"system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 15insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Town of Barnstable Geographic Information System A9ap Size „Zo6m Out .1. # Parcel Viewer custom Map Abutters }�, l , 3 In - i _ �+ r..y A3 I 3, � 1 i Q. r ti , , a � Q • ���''�.,�..-��' -.,4� Asa ti :, Oi tt _ 0 220 Feet ° f s t r Set Seale 1" m 20 Aerial Photos MAP DISCLAIMER a'`nn„rinht 9na1�.4a1t1R Tn,un of Ao,nriflhl® AAA All rinhic roeanr. littpxf`AN.-ww.town,barnstable.nia,tis/ai-eirliss'xppgeoal)li;`i»ap.tispx`.property]D=14101;OOA&... 4/27,12009 f Commonwealth of Massachusetts Ip Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments. 727 Main Street Bldg D) Property Address Wianno Knoll Condominiums Owner Owner's Name informatifor every on is required Osterville _ MA 02655 9-28-20 ._ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Check cellar ❑ Shallow wells s /VO 11 Estimated depth to high ground water: 12 + feet Please indicate all.methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1981 Date ❑ Observed site (abutting property/observation Bole 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: Per Design Plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 - i f Commonwealth of Massachusetts '-, Y` ,p Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments ' 727 Main Street(Bldg D) u� Property Address - Wianno Knoll Condominiums 4 Owner Owner's Name — — — information is OsterVille MA 02655 9-28-20 required for every — — page. City/Town State Zip Code, Date"of Inspection E. Report Completeness Checklist"a Complete all applicable sections ofrythis forrWinclusiv&of ® A: Inspector Information:aCompletehall fields in thissection. s ®. B. Certificati6n:,Signed.&'Dated"and 1, 2, 3;;or 4 checked ® CAnspection=Summary: a r 1, 2, 3,or.5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed a . ® :D.,System Information` For 8: Tight/Holding Tank T Pumping contract attached For 14: Sketch of Sewage Disposal System drawn,on pg. 16 or attached MFor 15: Explanation of'estimated'depth to high groundwater included k 7,' ra t5insp.doc-rev.7/26'2018 `` Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ,,. Apr. 0 2018 20:53 HP Fax page 1 'y Commonwealth of Massachusetts Title 5 Official Inspection Form .:J i� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .,ti t 727 Main Street(Bldg D + Property Address ' r: Wianno Knolls Condominiums ; Owner Owners Name r , information is Osterville MA 02655 3-29-18 required for every __. page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms ��.�- � a9 q D `�N�1t111V111H1p714'' on the computer, ���`���H OF A't9s use only the tab 1. Inspector: ��•' 9C, key to move your o: G cursor•do not JAMES use the return James D.SearS !�: _ key. Name of Inspector Cap Company Name ewi Enterprises F o �� 153 Commercial Street I N SVE �`' Company Address mono Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority izzlin AA!!� r 3-31-18 IqOgctor's signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15imcloc•rev.61'16 Title 5 Official Inspecilon Form:Subsurface Sewage Disposal System-Page 1 of 17 �O I"s Apr 03, 2018 20:53 HP Fax page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form .Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osteryille MA 02655 3-29-18 required for every I page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary, Check A,B,C,D or E!always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 2500 Gal, Tank D Box and 4 Pits. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Apr 03, 2018 20:53 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 Main Street (Bldg Main Street (Bldg Dom. Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osteryille MA 02655 3-29-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) i ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(cost.): ❑ 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 Mns.00c-rev.6/16 Title 5 Ofhdal Inspection Form:Subsurace Sevwege Disposal System-Pape 3 of 17 page 4 Apr 0� 2018 20:53 HP Fax Commonwealth of Massachusetts Title 5 Official Inspection Form UqSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street (Bldg D Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville MA _02655 3-29-18 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into,facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in MmMM is less than 6" below invert or available volume is less than %day flow P(T�S 15ins.doc•rev. t1b Title 5 Official InapKuon Form:Subsurface Sewage Disposal System•Page 4 of 17 Apr 03 2018 20:53 HP Fax page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osteryille MA 02655 3-29-18 otylTown page 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. ❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet y>� P� p vY 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 forma ❑ ® The system is a cesspool serving a facility with a design flow of 20009pd- 10,000g pd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 Df 17 i Apr 03, 2018 20:54 HP Fax page 6 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owners Name information is required for every Osterville MA 02655 3-29-18 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 NIA) ® ❑ 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): B Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 tsins.doc-rev.afi6 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System,Page 6 of 17 f Apr 05 2012. 11:20 HP Fax page 1 c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every osterville MA 02656 3-29-18 page. Cityrrown state Zip Code Date of Inspection D. System Information Description: 2500 Gal. Tank D Box and pits. Number of current residents: • Unknown. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) i Laundry system inspected? - ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP )}� Detail: Sump pump? ❑ Yes C NO Last date of occupancy: Present Date CommerciallIndustrial 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. t5lns.doc-rev.6M6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 e 17 Apr 03, 2018 20:54 HP Fax page 9 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 3-29-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information; Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5lns.doc•rev.6118 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Apr 03 2018 20:55 HP Fax page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form k;4w," Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 3-29-18 page. CityrTown 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: 2'feet Material of construction: ❑cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" SCH 40 PVC. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years " Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2500 Gallons Sludge depth: 3 t5uis.doC•rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Apr 03, 2018 20:55 HP Fax page 11 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums owner Owner's Name information is required for every Osterville MA 02655 3-29-18 page. Cityrrown 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 49" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 1 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Plan -Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level with 2 inlet tees. Outlet tee inlet steel cover at grade. Outlet cover steel 2" below grade. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.do1•rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Apr 03 2018 20:55 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street(Bldg D k'4'��Fwj 9 Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 3-29-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.}: *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.tloc-rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pape 11 of 17 Apr 03 2018 20:55 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville required for every MA 02665 3-29-18 C' page. �y/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 C Comment (n ote ote if box is level( and distribution ut on to outlets equal, an evidence of solids carryover,an Y rY Y evidence of leakage into or out of box, etc.): D Box is clean and solid 22" below grade, With 18" cement cover at 4" below grade, 4 lines out no sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 12 of 17 f Apr 03 2018 20:56 HP Fax page 14 �sny Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville required for every MA 02655 3-29-18 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.): Leaching is 4 precast pits with steel covers at grade, Pit 4-2'water. Pits 5-6-7 1'water. 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 150s.doc-rev.8116 Title 50flicial Inspection Form:Subsurface Sewage 6lsposal Syster-Page 13 of 17 Apr 03 2018 20:56 HP Fax page 15 Commonwealth of Massachusetts : p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 727 Main Street (Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 3-29-18 page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dime nsions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Apr 03 2018 20:57 HP Fax page 16 Commonwealth of Massachusetts o Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not r g p y for VoluntaryAssessments 727 Main Street(Bldg D) Property Address Wianno Knolls Condominiums Owner Owner's Name Information Is required for every Osteryille MA 02655 3-29-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5lns.doc•reu.6/16 Title 5 Oftlall Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Apr 03 2018 20:57 HP Fax page 17 Mar21 18, 12-.00p Capowids Enterprises 508-477-4977 p.7 Ormation sy te uv PEE-i-L;I T21--n-I ------ Of 4!V: • Y- AC 0 J twet Scale IWT4- MAP DISCLArol,".1i Apr. 03 2018 20:58 HP Fax page 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System form-Not for Voluntary Assessments 727 Main Street(Bldg D) Property Address Wiianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 3-29-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated t depth gh ground water: 12+ p hi 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: ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Per Design Plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins.dac-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal SyMem-Page 16 cf 17 Apr.03 2018 20:58 HP Fax page 19 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments hAp Vy. 727 Main Street (Bldg D) Property Address - Wianno Knolls Condominiums Owner Owner's Name information is required for every psteryille MA 02655 3-29-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5irts.doc•rev.6r16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i i I(/ .- co '3 '7 ©Cl/l1 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner owner's Name information is required for every Osterville MA 02655 4-15-15 page. City/Town State Zip Code Date of Inspectio 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. Im :When A General Information fillingng out out forms A.orms on the computer, ( c5 I CI`���� 1H OF MqS,'r9P use only the tab 1. Inspector: �'G key to move your p� •.yG cursor-do not James D. Sears =g JAMES R,= use the return Name of Inspector c�; key. Capewide Enterprises,LLC cl p *: Company NameTI •G 64 153 Commercial Street sP1E1 0�, Company Address Mashpee Ma 02649 City(rown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑•Fails ❑ Needs Further Evaluation by the Local Approving Authority. 4-15-15 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector-and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""*"This report only describes conditions at the time of inspection and under the co diti ns of use at that time.This inspection does not address how the system will roorm in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface ge Disposal System•Page 1 of 17 1 1 4 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville MA 02655 4-15-15 required for every - page. Cityfrown State Zip Code Date of inspection B. Certification (cons.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 2500 Gal. Tank D Box and 4Pits.. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank.failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below.): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments yy< 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osteryille MA 02655 4-15-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a:surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Inspection Form - Tale 5 Official p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg- D Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville MA 02655 4-15-15 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 eavaW is less than 6"below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is Osterville MA 02655 4-15-15 required for every page Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 El Area system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner owner's Name information is required for every Osterville MA 02655 4-15-15 page. City/Town State Zip Code Date of Inspection. C. Checklist Check if the following have been done. You must indicate"yes"or°no°as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not. available note as NIA) ® ❑ 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): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880 t5ins-11/10, Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments SVO, 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. City/Town State Zip Code Date of Inspection. D. System Information Description: The system is a 2500 gal.precast tank., D Box and 4 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 NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease e e trap present. El Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wanno Knolls Condominiums Owner owner's Name information is Osterville MA 02655 4-15-15 required for every page. Citylrown State Zip Code Date of Inspection. D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..�� 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): _ . Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" SCH 40 PVC. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list a, age. years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2500.gallons Sludge depth: 2„ t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy< 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name require for is Osterville MA 02655 4-15-15 required for every page. Citylrown 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 48 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 14" � How were dimensions determined? Plan Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level with 2 inlet tees.Outlet tee inlet stee coverl at grade.0utcover steel 2"below grade. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M �'( 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 page. City[Town State Zip Code Date of lnspedion 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)�(Iocate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is clean and solid 22"below grade, with18"cement cover 4"below grade. 4 lines out No sign of over loading or solid carry over.t I 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. Cityrrown 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 s Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is 4 precast pits with steel covers at grade. Pit's 4-5-7 2'Water, Pit 6 is Full. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert. Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bld g. D 9� Property Address Wanno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15A5 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells No Estimated depth t high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 1981 If checked, date of design plan reviewed: Date Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ® Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the-high ground water elevation: Per Design Plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 727 Main Street Bldg. D Property Address Wianno Knolls Condominiums Owner Owner's Name information is required for every Osterville MA 02655 4-15-15 page. Cityrrown State Zip Code Date of Inspedion 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �A C F f s � e '9M1, yv0 350 MAIN STREET WEST YARMOUTH, MA ..57 508-775-2800 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 D 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: 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. : e. _ NOTES AND COMMENTS: BLDG. D 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. CD C_ t~: 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 D 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING D 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 Owner: WIANNO KNOLL CONDO—BUILDING D 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 16.303. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 727 MAIN STREET,OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING D Date of Inspection: JULY 20, 2006 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): N/A Sump Pump(yes or no): NO Last date of occupancy: N/A COM MERCIAUINDUSTRIAL: Type of establishment: Design flow: Gpd(Based on 15.203) 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 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: 1980 Sewage odors detected when arriving at the site:(yes or no) NO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BULDING D Date of Inspection: JULY 20, 2006 BUILDING SEWER: (Locate on site plan) Depth below grade: 14" 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: 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: 4" Distance from top of sludge to bottom of outlet tee or baffle: 46" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 26" 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.) TANK AT WORKING LEVEL,OUTLET-.__TEE OR __.B'OTH COVERS T STEEL INLET COVER AT GRADE. OUTLET COVER 3"BELOW GRADE.NO SIGN OF LEAKAGE OR OVER LOADING,INLET COVERS NEED TO BE RE-CEMENTED. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET Owner: WIANNO KNOLL CONDO—BUILDING D 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 2'20"BELOW GRADE.BOX IS LEVEL,CLEAN&SOLID. NO SIGN OF LOADING OR SOLID CARRY OVER WITH COVER AT GRADE. ONE LINE IN—FOUR LINES OUT. 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 D Date of Inspection: JULY 20, 2006 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 1000-GALLON PRE CAST PITS,ALL PITS HAVE 1'WATER,NO HIGH WATER MARK. _ TWO PITS HAVE 2'STEEL COVER AT GRADE.ONE PIT COVER 2'STEEL 3"BELOW GRADE. ONE PIT 2'STEEL COVER AT GRADE. CESSPOOLS: N/A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING D 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. 1 SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING D 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 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 GROUND WATER-SITE HIGH. 7�-l• G,�A � � Ba�n� A 1 7— NO 3 Y I ee Sf p it t °7 r oj , gr t i3S® COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION e 350 MAIN STREET WEST YARMOUTH,MA �0 508-775-2800 TITLE 5 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 D OSTERVILLE,MA 02655 FRECEIVED Owner's Name: WIANNO KNOLL CONDOMINIUMS Owner's Address: PO BOX 1073 OSTERVILLE,MA 02655 2003 Date of Inspection JUNE 25,2003 Name of Inspector:(please print) JAMES D. SEARS TOWN OF BARNSTABLEHEALTH DEPT. 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 4 I ****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 e Page 2 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 D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ./ J I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 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 6/15/2000 2 t , 1 Page 3 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 727 MAIN STREET-BUILDING D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 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: d Title 5 Inspection Form 6/15/2000 3 L 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 D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 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 pit is less than 6"below invert or available volume is less than''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation 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 ` 1 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 D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation 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 nonnal 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 infonnation. For example,a plan at the Board of Health. ✓ Detennined 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 727 MAIN STREET-BUILDING D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 FLOW CONDITIONS RESIDENTIAL-CONDOMINIUMS Number of Bedrooms(design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 880 Number of current residents: 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: N/A COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 31-0 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: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonmation: ANNUAL PUMPING Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1980 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET-BUILDING D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 BUILDING SEWER(locate on site plan): ✓ Depth below grade: Materials of construction: Cast iron 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: Material of construction: ✓ concrete metal fiberglass polyethylene. _ other(explain) If tank is metal list age: Is age contnned by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 48" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 24" How were dimensions detennined: PLAN AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.OUTLET BAFFLE.BOTH COVERS 2' STEEL.INLET COVER AT GRADE. OUTLET COVER 3"BELOW GRADE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete _p 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.):, a i Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET-BUILDING D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 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 18"06",20"BELOW GRADE. BOX IS LEVEL AND SOLID.ONE LINE IN, FOUR LINES OUT. 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 l Page 9 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 D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 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.) FOUR 1,000 GALLON PRE CAST PITS.ALL PITS HAVE 14"WATER,NO HIGH WATER MARK.TWO PITS HAVE T STEEL COVERS AT GRADE.ONE PIT COVER 2' STEEL 3"BELOW GRADE.ONE PIT 2' STEEL COVER 18"BELOW GRADE. 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 groundwate-inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: NiA (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.) Title 5 Inspection Form 6/15/2000 9 I� Page 9 of]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 D OSTERVILLE,MA 02655 Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0 O 0 Title 5 Inspection Form 6/15/2000 10 Page 1 1 of 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 D OSTERVILLE,MA 02655 ' Owner: WIANNO KNOLL CONDOMINIUMS Date of Inspection: JUNE 25,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater over 12 feet Please indicate(check)all methods used to determine the high ground water elevation: ./ Obtained from system design plans on record-If checked,date of design plan reviewed:. 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 AT 12'. Title 5 Inspection Form 6/15/2000 11 COMMON WEAUPI I OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO'ITCTION - �,�� ONE WINTER STREET, BOSTON MA 02109 (617) 292-5500: .4'. TRI.TDY COXF 350 MAIN STREET Secretary ARGEO PAUL CELLUCCI WEST YARMOUTH, MA bi i� «"Governor 508-775-2800 D +` AVID C B. STRUIiS omniissioner 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 D I am a DEP approved system inspector pursuant to Section 15.340 of Title;5:0310 CMR 15.000)` COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth;MA 02673 e. 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 Y CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVINGAUTHORITY 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 D.EP) 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 SYS.TEM: lip Y T. revised 9/2/98 1 °��`' c'��p A . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIVICATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING D 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 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 leveled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING D Date of Inspection: J'ANUARY 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 D , 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 16.303. 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 D 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)[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. 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 D 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 COM MERCIAUINDUSTRIAL: Type of establishment: Design flow: Gpd(Based on 15.203) 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 boxisoil 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 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO-BUILDING D 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: 14" 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 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 48" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 24" How dimensions were determined TAPE&ASBUILT 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,TWO INLET LINES WITH TEE'S.BOTH COVERS STEEL AT GRADE,OUTLET BAFFLE. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised 9/2/98, 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET,OSTERVILLE ' . Owner: WIANNO KNOLL CONDO-BUILDING D 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 18"X36",20"BELOW GRADE,ONE LINE IN,FOUR LINES OUT.D-BOX HAS BEEN REPLACED 1998 PERMIT#198-104 PUMP CHAMBER: NIA (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 p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING D 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)PER CAST PITS.6'PITS 4"—6"WATER IN PITS.NO HIGH WATER MARKS.TWO(2)PITS IN BLACK TOP,STEEL COVERS AT GRADE ONE(1)PIT IN GRASS COVER 8"BELOW GRADE.ONE(1)PIT IN GARDEN,COVER 18"BELOW GRADE. CESSPOOLS: N/A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure, ,level of ponding;condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN FOR MATION(continued), Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO=BUILDING D 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) O 0 E ,O e revised 9/2/98 10 r 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, OSTERVILLE Owner: WIANNO KNOLL CONDO—BUILDING D 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 no to 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 4 (�OMMONW( nl,'L11 1jXT;('U.11VI, UT'FIC;r OF 1',NVIItONMI,N'I'nL, nr /1 • .� �! lll31.1A IME P a ENVM0NMIWVAL PRO'1E � ,C)N �.� ONE WIN11;It S'IRPL'1', 110S'i'ON MA 02109 (617) I,92-5fi0f) 350 MAIN STREET WEST YARMOUTH, MA �F RUi)��)Xy gear 508-775-2800 ARGEO PAUL CFIAAJCCI DAVI.1� FRUI19 Governor Z G nmissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 141 PAR 01 OOK PROPERTY ADDRESS: 727 MAIN STREET, BLDG D, OSTERVILI_E ADDRESS OF OWNER: DATE OF INSPECTION: JUNE 1, 1999 WIANNO KNOLL CONDOS NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A& B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: 50f3 775-2000---------- — --- - 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 q INSPECTORS SIGNATURE: � �s b DATE: y� / 9 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. revised 9/2/98 I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIVICATION(continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: YES I have not found any information which indicates that the systern 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 leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1. 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 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 f a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 D] SYSTEM FAILS: NIA You must indicate either"Yes"or"No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CNIR 16.303. 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'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the 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 wafer 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 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: } Yes No X Pumping information was provided by the 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. } k � < a revised .9/2/98 5 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 880 g.p.d./bedroom for S.A.S.# r Number of bedrooms(design) 8 Number of bedrooms(actual):: 8 Total DESIGN flow Number of current residents: N/A" r Garbage grinder(yes or no): NO ` Laundry(separate system) (yes or no): NO If yes,separate inspection required M•y - ` 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 on16.203) 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: , . I OTHER:(Describe) 3. • - _ fir;` :, Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) NO , If yes,volume pumped: gallons Reason for pumping 7- 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) k 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: 1980 Sewage odors detected when arriving at the site:(yes or no) a NO revised 9/2/98 6 4 ; � _ - [ .. ♦ µ.fir , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILL'E Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 BUILDING SEWER: (Locate on site plan) Depth below grade: 14"- x, Material of construction cast iron 40 PVC _ other(explain) Distance from private water supply well or suction line y Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: (Locate on site plan) Depth below grade: 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 baffler 48^ Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 24'•., How dimensions were determined PLAN AND 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.) TANK AT WORKING LEVEL,OUTLET BAFFLE BOTH COVERS 2'STEEL INLET COVER AT GRADE,OUTLET COVER 3"BELOW GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete metal Fiberglass — Polyethylene other(explain) Dimensions: — F 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: a (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 y { SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREE, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 TIGHT OR HOLDING TANK: N,'A (Tank must be pumped prior to or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete metal — Fiberglass Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallonsiday Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc:) DISTRIBUTION BOX: YES t (locate on site plan) Depth of liquid level above outlet invert: 0 s• Comments: k ; (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,,etc,) DISTRIBUTION BOX IS 18"X 36" 20"BELOW GRADE ' BOX IS LEVEL AND SOLID ONE LINE IN,FOUR LINES OUT 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.) 71 ------ $C' revised 9/2/98 8 „ h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS ' Date of Inspection: JUNE 1 1999 SOIL ABSORPTION SYSTEM (SAS): (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)1,000 GALLON PRE CAST PITS ALL PITS HAVE 1'WATER NO HIGH WATER MARK, TWO(2)PITS HAVE 2'STEEL COVER AT GRADE ONE(1)CPIT COVER 2'STEEL 3"BELOW GRADE,ONE(1)PIT 2'STEEL 18"BELOW GRADE CESSPOOLS: N/A , (locate on site plan) Number and configuration: k Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: R, Materials of construction: a G 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.) k revised 9/2/98 g Is SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' a SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE F Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 a SKETCH OF SEWAGE.DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1 00'(locate where public water supply comes into house) r SEE ATTACHED PLAN S , 4 . ` revised 9/2/98 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 727 MAIN STREET, BLDG D, OSTERVILLE Owner: WIANNO KNOLL CONDOS Date of Inspection: JUNE 1, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells r ' Estimated Depth to groundwater OVER 121EET 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 r= . 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 N(M�9D/ ..Y.M. Fim..20 THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH mu...... .....o F.................. � ,/ �� -. .. Appliratiou for 11itipu.ittl Warks Tnnitrurtiun Prrutit Application is hereby made for a Permit to Construct (�j�) or Repair ( ) an Individual Sewage Disposal System at: ° Locati , dress r_ or Lo ner fAd es •- Installer Address - G'� dType of Building' // Size Lot................ :..... Dwelling—No. of Bedrooms...............1.,�..__..._____.__.__Expansion Attic ( ) Garbage Grinder K4C� Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures Design Flow............... W g ...&__________________gallons per person per ddy. Total daily/flow............../ ___�..�........gallons. WSeptic Tank—Liquid ca.pacit}? 11ons Length__.. -_._ Width.....6....... Diameter---------------- Depth....;:........ x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No....... Diameter./ _7 .. Depth below inlet_g':V.... Total leaching area.&O-70_..sq. ft. Other Distribution box O Dosing tank (a )�©&"/�i-J®i_ j p �Y Percolation Test Results Performed by...... x....... .................................�----•f--Z�e.A—Pate...... 14 Test Pit No.S _.___ -....minutes per inch Depth of Test Pit__.____ ______ Depth to ground water---��� '�- -- Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ / _.. = -- ------------------------- -------- Description of Soil......... _ L�' � & -----------------------•-- ----•-•-------- � � '� - "•C f— U ------------------•----......._....---•--•----•••-•-•. W ••-••.........................--•-•••-•••---•••••-•••-••--••--------••-••-•-•---••••-•-------•-•-••-----•-- - ------------------ ........................ ................ U Nature of Repa• ' or Alterations—Answer when applicable_._ Agree ent h i igned grees to install the aforedescribed Individual Sewage Disposal System in accordance with IIS Ot L c.:f 5 of the State Sanitary Code— The undersigned further agrees not to place the system in e atil a Certificate of Compliance has been issued by the board of health. Ito nl Signed 7.3 --... 2 ..._ - ----•------- -----------------_-_------ ...------- -• .__ U ICK �.�+ Date Icati t%% roved B �:,1��.... W ---z! /PP y. ..................... Date .... F isapproved for the following reasons---- ----------------•-------•-----------------------•--•------------=----------••--------------------.....-•••- ��NAL-ECG\ -----•......-•_...----•-••-••-- 3C..--;,�J_��:5'1---------••.........................•----•---------...-•---•-----......_..---------------�- Date PermitNo......................................................... Issued-----.._......-•--------._.....•-•••-------------•..... Date No ZZ - FEs.... .............. THE COMMONWEALTH OF MASSACHUSETTS SOAR® , HEALTH Appliration for Ui_qpnsttl Works Tnnstrnrtiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a� 7 ..............._...l- .....-.. � -�-or.Lt G✓.. I-+--�-/_..G.••_- - Location re fl ..................t----------•----•-•-.._.... ...-•--•. ..... .- r " y :�,�.:.:........ Owner - Ad�a�'�e�s,�/ Ln Installer Address S d Type of Building Size Lot______ ________ _________Sqf y U - n Dwelling—No. of Bedrooms.............../ __..__.___.._._.__Expansion Attic ( ) Garbage Grinder (1100 5 Other—Type T e of Buildii, No. of ersons____________________________ Showers — Cafeteria a YP ,.,.fig ------•-•------------------• P ( ) ( ) Q' Other fixtuges.�.--------------------------------------------------------------------------------------------------------------------------------------------------- Design Flow................�5._S.__..._..........__gallons per person per dj . Total daily 6w............... . � .......galloz{. WSeptic Tank—Liquid capacity�.a lons Length___._ ____ Width._.__...... Diameter.......__.._`___ Depth.....6....... x Disposal Trench—No..................... Width______ii_;_ _._____._ Total Length..__________ ...___ Total leaching area....................sq. ft. 3 Seepage Pit No._____. _______- Diameter../ Depth below inlet__ _` /./c'.__ Total leaching area._ P._sq. ft. Other Distribution box ( Dosing tank '-' Percolation Test Results Performed by....... h r s i__ ate aTest Pit No. ......Z...minutes per inch Depth of Test Pit........ .____ Depth to ground water_.- ............. Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ !I ---------------•- ------ c.,.. .. Description of Soil.......... 1 ...... - I.._......... �Go c�/'SE S �rit J W ----•--------------------------- ---------------------•------------------------------------------------ _ ----------------------------------•----------------------••-----•-••-•-•--••-- UNature of Repair or Alterations—Answer when applicable... '........ ...---•••--•-•-------------•` ---------••---•-•------------.._...----._._._.._.............._...---•----...----•--------------------------•------------------------------._.._._....._..._......--•- Agree nt: r'� I nd' gned � rees to install. the aforedescribed Individual Sewage Disposal System in accordance with X q p[ a Q�n of A IT1S 5 of the State Sanitary Code—The undersigned further agrees not to place the system in f �M, •er r ; ntil a Certificate of Compliance has been issued by the board of health. .•'•fir Signed----- 19 f ..........C., ,� D�a e tIEYl roved B '� /- •//r" i - �` - j'%'9/-----------PP Y----•---- — ...........:...... ...,... to Date pQpplie�t(•�(,n isapproved for the following reasons__________________________________________••----------------••-•-----------•-----------•----- -----...------ Vv �`S/OIVAL E.�1r'\�- ------------•------....--•--......---•---•-----.,.........__.._..._...----------•---•---•-•-----------------------•-----•---•---••--------------------------•-•- -•----•---•--- Date PermitNo......................................................... Issued....................................................... Date f THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ...........,./. 4.4 V ..-..-OF. : ....... ................................•----- Trrfifiratr of Tuutphatt r THIS IS TO CERTIF ', That the Individual Sewage Disposal System constructed or Repaired ( ) r,,, _ �^ Installer ,� 0 at............. l -----••. 2 ? � %' I I - �, � <�I ram- ------•----•�r�__a X 7_ has been installed in accordance with the provisions of TITIL- r of The State Sanitary Code as described in the application for Disposal Works Construction Permit 1//........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BXCONST E AS GUARANTEE THAT THE SYSTEM W1 C F CTION SATISFACTORY. DATE' ...S ...a 1 Inspecto ---- ---�---- -. .._..:----•---•-----...---------.......--- T THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ...............OF.. __•__ _• -•-- No ..`///•_ FEE..... ............... "Disposal Works Tonstrudiotf vs ut t r� , Permission is •ereby granted..............--�--_-------�;-----�=�--=-=�•--�------------�G���u.�...---------•--•----------........_............... to Construct ( �or Repair ( ) an Individual�Sewage Disposal System atNo. = ...................................................... _ � _--------•--- Street l as shown on/thea/pica 'on for Disposal Works Construction Permit No_____________________ Daled_. _.7-�.__.? ______........ --------------------------------------- Board/ofHealth DATE_--• ................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS A �s