HomeMy WebLinkAbout0727 MAIN STREET (OST.) - Health (7) 727 MAIN ST., BLDG G, ®STERVILLE
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Commonwealth of Massachusetts y-1 -0k 3~�"
n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street (Bldg. G)
V�
Property Address •
Wianno Knolls Condominiums
Owner Owner's Name *'
information is
required for every Ostervillls ✓ MA 02655 9-28-20
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.
OFUa
rrHiiiq,,
rmng out forms en A. Inspector Information /. c / g q�0 s'?�
on the computer, _ :• JAMES
use only the tab James D.Sears -
key to move your Name of Inspector s o: :Co
cursor-do not Robert B.Our Co. INC *
use the return ,
key. Company Name !�c' .. . ..• GC``���
363 Whites Path
s iNSP��```��`
rab Company Address
South Yarmouth MA 02664
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system-inspector.in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address,
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving°Authority
4. ❑ Fails
_9-28-20
pector'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 orgreater, the inspector and the system owner shall submit the report to.the appropriate
regional office of the DER The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page.1 6f 18
I
Commonwealth of Massachusetts
a
Title 5 Official Inspection Form
1-
h Subsurface Sewage Disposal System Form ;- Not for Voluntary Assessments
- p Y
727 Main Street(Bldg. G)
u-
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is
required for every Osteryillls MA - 02655 9-28-20
page. 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. E
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:
The system is a 2000 Gal. Tank D Box and 3 Pits. Note: Tank out let Tee has a Zable Filter.
2) System Conditionally Passes:
❑. One or more system components as described in the"Conditional Pass" section need to be "
replaced or repaired. The system, upon completion of the'replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N., ND) for the following statements. If"not
determined,":please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial,infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass,inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that`the tank is less than 20 years old is available.
❑ Y ' ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
w _ Title 5 Official Inspection Form w
Voluntary I Subsurface Sewagep Y Disposal System-Form Not for Assessments
u
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums-
Owner Owner's Name
information is
required for every Ostervillls MA 02655 -9-28-20
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. Systemwill pass unless Board of Health determines in accordance with.310.CMR .
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 18
f
Commonwealth of Massachusetts
I� Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street (Bldg. G)
u� Property Address
Wianno Knolls Condominiums _
Owner Owner's Name
information is required for every Ostervillls 'MA 02655 9-28-20
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 atone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no.other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Ostervillls MA 02655 - 9-28-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
99 P
Liquid depth in is less than 6" below invert or available volume is less
❑ ® T 1
than /day flow �� S
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 1 00 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...
❑ ® The system fails. I have•determined that one or more of the above,failure K ,
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.
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
El.
El :Area-
system is located in a nitrogen sensitive area (Interim Wellhead Protection
. :Area"—IWPA) or a mapped Zone lI`of a public water supply'well h :
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•`Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls MA 02655 9-28-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.),
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information.was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period? .
El ® 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?
® El 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.
El ® Determined in the field (if any..of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)] '
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- iI Subsurface Sewage Disposal System Form Not for Voluntary Assessments
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls MA 02655 9-28-20
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 8 Number of bedroom's (actual): 8
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880
Description:
The system is a 2000 Gal. Precast Tank, D Box and 3 Pits.
• Number of current residents: Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ ;Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readin s, if available last 2 Mears'Osage NA
9 ( Y 9 (gPd))�
L Detail:
Sump pump? ❑ Yes ®. No
Last date of occupancy: Present'
Date
` t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
�I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
727 Main Street (Bldg. G)
V
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Ostervillls MA 02655 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 waste holding tank.present?. ❑ Yes ❑ No
Non-sanitary waste discharged to1.he Title 5 system? ❑ ,Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: b Date
Other(describe below):
3. 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:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
f
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street(Bldg. G) `
u Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls MA 02655 . 9-28-20
page. City/Town - State Zip Code Date of Inspection...
D. System Information (cont.)
4. Type of System:
. t
® 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 theI/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):
2
Depth below grade': feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: K feet
Comments (on condition of joints, venting, evidence of leakage, etc.):.
Piping is 4" Sch 40 PVC.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
727 Main Street(Bldg. G)
u Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls f MA 02655. 9-28-20
page. City/Town State, Zip Code= Date of Inspection
D. System .Information (cont ) .
a 6. Septic Tank(locate on site plan):
. 18„
Depth below grade: feet
Material of construction:
® concrete ❑ metal 1 ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: Y.
- - ,.years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate),. ❑ Yes ❑ No
Dimensions:
3"
2000 Gallons
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness
` 811
Distance from top of.scum to top of outlet tee or baffle-
17
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 in and outlet tee. Botfi covers are steel, at grade. No sign of leakage or over
loading. Note: Tank outlet Tee has a zable filter.
t5insp.doc-rev.7/2k018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts J
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary,Assessments •
h
u
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Ostervillis MA 02655 9-28-20
required for every `
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations,_inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate`on.site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal' ,❑fiberglass ❑ polyethylene ❑ other-(explain): ..
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls MA' 02655 9-28-20
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.):
*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 3' below grade with steal cover at grade. 3 lines out. No sign of over loading
or solid carry over.
t5insp.doc-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18,
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls MA 02655 9-28-20 .
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ElYes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): .
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 3
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
+- �11; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street(Bldg. G F
V
Property Address
Wianno Knolls Condominiums. .
Owner Owner's Name
information is required for every Clstervillls MA 02655 9-28-20
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.)
r -
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 3 precast pits. 2 in Black Top.Driveway with steal covers at grade. One offdriveway with
steal cover T below grade.-Pit 3 is full. Pits 4-5 have 1' of water.
12. Cesspools (cesspool must be pumped as part of inspection),(locate on site plan):
Number and configuration
Depth =top-of liquid10 inlet invert
Depth of solids layer
y
Depth of scum layer —
Dimensions of cesspool , V
Materials of construction
Indication of groundwater inflow- ❑ Yes ❑ No
Comments.(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
s
R '
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
I
Title 5 Official Inspection Fora
�i; Subsurface Sewage Disposal System Form Not for Voluntary Assessments
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Ostervillls 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.):
6 •
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of,18
Commonwealth of Massachusetts
1F _ Title 5 Official Inspection ForrYM
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street(Bldg. G)
V�
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Ostervillls MA 02655 9-28-20.
required for every —
page. Cityfrown 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
�i� Subsurface Sewage Disposal System.Form Not4or Voluntary Assessments.
727 Main Street(Bldg. G)
Property Address
Wianno Knolls Condominiums - `
Owner Owner's Name
information is
required•forevery Ostervillls MA 02655 9-28-20-
page. City/Town State Zip Code Date of Inspection
iD., System Information (cont.) �
15. Site Exam:
® Check Slope
® Surface water-
Check cellar
❑ Shallow wells '
No 12'+
Estimated'depth toFgh ground water: feet
Please indicate all methods used to determine the high ground water elevation;
® Obtained from system design plans on record
If checked;date of design plan reviewed: pate
❑ 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:
\y
You must describe how you-established the high ground water elevation:
Per Design Plan.
h klist on next page.
Completeness C ec
Before filingthis Ins ection'Re `ort lease see Report
p p , p pP 9
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street(Bldg G)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Ostervillls MA 02655 9-28-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
d
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
1
Commonwealth of Massachusetts-
-, Title 5 Official Inspection Form +o 1 +1 -
1-
.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V 727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name /
information is osterville ✓ MA 02655 3-15-18
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 airy
way. Please see completeness checklist at the end of the form.
Important:When Arms . General Information
filling
the computer,oSir (a
o OF
use only the tab
1. Inspector: 0
_;• y
key to move your =�;• JAMES
cursor-do not James D Sears
use the return
key. Name of Inspector
Capewide Enterprises, �,•,c+ o.
ICI Company Name i ��•`cTTr��—�` .
153 Commercial StreetiNsp����o\`
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3-16-18
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
LOW V
v.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 2000 Gal. Tank D Box and 3 pits. Note: outlet Tee has a Zable filter.
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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 3-15-18
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than %day flow Vr?T
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
l
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
•V
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year 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 31.0 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 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?.
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?,
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 10 Number of bedrooms (actual): 10
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1100
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G._
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
2000 gal. Tank, D Box and 3 pits.
Number of current residents: NA
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 years usage d NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
V
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 3-15-18
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes E 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" SCH 40 PVC.
Septic Tank(locate on site plan):
Depth below grade: 18"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: yearn
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 2000 Gallons H-20
Sludge depth: 311
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
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
31"
1
Scum thickness
8„ i
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Plan Tape i
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 in and outlet tee. Both covers steel at grade. No sign of leakage or over
loading. Note: Outlet tee has a zable filter.
Grease Trap (locate on site plan):
Depth below grader 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.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate 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: bate
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
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 3' below grade, with steel cover at grade. 3 lines out. No sign of over
loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 3
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool, number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is 3 precast pits. 2 in blacklop driveway with steel cover's at grade. One off driveway with
steel cover 2" below grade. Pit's have 1'water. No sign of over loading or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
• c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Fro Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street Bldg G.
V
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA .02655 3-15-18
required for every _
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Map Page 1 of 2
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Na
Estimated depth to high ground water:_ 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1981
Date
❑ Observed Site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per Design Plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- FIo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
727 Main Street Bldg G.
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 3-15-18
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems).completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on.page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
l
Commonwealth of Massachusetts
Ti#le 5 Official Inspection Form -7
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Cityfr6wn State Zip Code Date of.Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.-Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
-
on the computer, I �O�` �r10Frilg4S%,,�.
use only the tab 1. Inspector: S .e`����
key to move your O�� '•yG
cursor-do not James D. Sears JA M ES
e the return Name of Inspector
ke = :y
Y
Capewide Enterprises,LLC '* ' •*c
Company Name
153 Commercial Street '�iF 5 I N SIP'e``'�`
Company Address
Mashpee Ma 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 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
OR'spectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future antler
the same or different conditions of use.
l5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal IStem
Commonwealth of Massachusetts
ID
.21 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
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
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 2000 Gal. Tank D Box and 3 pits.
13) 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 tnspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ..' 727 Main Street Bldg. G
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
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M �( 727 Main Street Bldg. G
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
B. Certification (cont.)
2. System will fail unless the Board of Health (and'Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance: '
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable,to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
,Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cmapaMif is less than 6" below invert or available volume is less
than%day flow A,7 V
t5ins-11H0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and, nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"_in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
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
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 880
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M a 727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. CityrFown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 2000 gal precast tank,D Box and 3 Pits
Number of current residents:
unknow
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: Present
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ 'No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments
727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums -
Owner Owner's Name
required fo is Osteryille MA 02655 4-15-15
required for every
page. Cityfrown 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 age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
2000 gallons
311
Sludge depth:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
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
31"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
17"
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.):
Comments(onpumping recommendations, inlet and outlet tee or baffle condition,structural
integrity,liguid levels as related to outlet invert,evidence of leackage,etc.):Tank at working level in and
outlet tee, Both covers steel at grade. No sign of leakage or over loading
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass , ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
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 3' below grade, with steel cover at grade. 3 lines out. No sign of over
loading or solid carry over.t
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street Bldg. G
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 (cunt.)
Type:
® leaching pits number:
3
❑ leaching chambers number:.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: .
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is 3 precast pits.2 in black top driveway with steel cover's at grade. One off driveway with
steel cover 2" below grade. Pit 3 is full. Pits 4-5 have 1' of 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 `
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt:)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
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.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
is
[S x a^
QL1 4
.r w
p �
r
ME
MEN
e
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s` ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street Bldg. G
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.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 1 feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1981
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
As-Built Card
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per Design Plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title '5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M °y 727 Main Street Bldg. G
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
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
f
Commonwealth of Massachusetts ' "� �L1 -0i3 -Jim Ai)
Title 5 Official Inspection Form :t
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St. Bldg. G } `
Property Address
Wianno Knolls Condominiums • �- l `
Owner Owner's Name
information is required for every Osterville Ma 02655 4-9--12.
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:out forms A. General Information
filling out forms ZN OF
on the computer,
use onlythe tab * :�;0 •••..•.•,••S9��''
1. Inspector: off;' •.�y
key to move your - G „
cursor-do not James D. Sears �'
DAMES :N-
use the return _ �•0. c,�—
key. Name of Inspector * _ ,
Cape wide Enterprises, LLCZF
Company Name
mb P Y I N SP��'
153 Commercial St.
Company Address °
•
Mashpee Ma 02649
Cityrrown 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 1f&M of
Title 5(310 CMR 15.000). The system: ;
® Passes -❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-11-12
'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 ghjpuld be sent to the system owner
and copies sent to the buyer, if applicable, and fK-approvingauttority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address-h_ow�het}sy1jst)oTwill perform in the future under
the same or different conditions of use,
a
ge Disposal System•Page 1 of 17
l5ins i i I/10 Title 5 Official Inspection Form!Subsurfa Se
r •
4
`i t • .
Commonwealth of Massachusetts
Title 5 Official Inspection Form ; T;
Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
yr. 727 Main St. Bldg. G
a
Property Address
Wianno Knolls Condominiums '
Owner Owner's Name "
information is Osterville Ma 02655'' 4-9-12 '
required for every .
page. Cityrrown "'.State Zip Code Date of Inspection
B. Certification (cont.) F
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: `
® [ have not found any information which indicates that any of the failure criteria described j
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments: ±
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass. A
Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
` - A
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
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available:
❑ Y ❑ N ❑,ND(Explain below):
t5ins-11110 Tide 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 2 of 17
;
�-\ Commonwealth of Massachusetts
Title 5 Official Inspection Forme j
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u
°t 727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums ~
Owner Owner's Name
information is required for every Osterville Ma 02655 4-9-12'
page. Cityrrown State Zip Code Date of Inspection
B. Certification.,(co'nt.)
B) System Conditionally Passes(cunt.):.
❑ Observation of sewage backup or break out or high static water level in the distribution box dtie
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): r
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 Lhealth, 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 6f,17
i Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3'
727 Main St. Bldg. G
Property Address F
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville 'Ma 02655 4-9-12 _
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has'a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of i 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 legs 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.
f
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 pond of effluent to the surface of the ground or surface waters
❑ ® - ,due to an overloaded or clogged SAS or cesspool,
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
` Liquid depth in cesspool is less than 6" below invert or available volume is,less
❑ ® than Y2 day flow
t5ins•11/10 Tide 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17
` Commonwealth of Massachusetts `
. Title 5 Official Inspection Form . ,
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums
Owner owner's Name
information is Osterville Ma 02655 4-9-12
required for every •
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any.portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El Z - Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP,certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal,to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the'analysis
-and chain of custody must be attached to this form.] '
0 ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. 1,have.deter-mined 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
❑ rE1 the system is within 200 feet of a tributary to a surface drinking water supply
0 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-11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 a
Commonwealth of Massachusetts'
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main St. Bldg. G X. ,
Property Address
Wianno Knolls Condominiums v r
Owner Owner's Name
information is Osterville Ma 02655', 4-9-12. '
required for every ,
page. Cityrrown State Zip Code `Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No '
Pumping information was provided by the owner, occupant,'or Board of Health
® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced'to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not '
® _ El available note as N/A)
® ❑ Was the facility or dwelling inspected for.sig is`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 differentfrom 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): Number of bedrooms(actual): V
880
DESIGN flow based on 310 CMR 15.203(for example 110 gpd x#of bedrooms): _ k
tJ
t5ins•11110 + Title 5 official Inspection Form:Subsurface Sewage Disposal System-.Page 6 of.17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St. Bldg. G
Property Address fi
Wianno Knolls Condominiums '
Owner. Owner's Name r
information is Osteryille Ma 02655 4-9-12
required for every
page. Citylrown State -'Zip Code Date of Inspection
D. System Information
Description:
The system is.a 2000 gal precast tank, D Box and 3 Pits
own
Number of current residents: unknown
�� � •• _ _
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ' ❑ .Yes ® No
Laundry system inspected?, ® Yes ❑ No
Seasonal use?. ❑ Yes ® No
Water meter readin s,-if available last 2" ears usage d na
9 ( Y 9 (gp ))�
Detail:
Sump pump? E•Yes Z No
Present
Last date of occupancy: Date
Commercial/industrial flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203). Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease'trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ' ❑ Yes ❑ No
Water meter readings;if available:
t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection .Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums ,
Owner Owner's Name
information is required for every Osterville Ma 62655 - 4-9-12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date a r M
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: w
® 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 Ins pection Form:Subsurface Sewage Dispose)System'-Page 8 of 17
i s
Commonwealth of Massachusetts
Title 5 Official Inspection Form .. ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St. Bldg. G
Property Address
Wianno Knolls Condominium's '
Owner Owner's Name
information is required for every Osterville Ma 02655
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) ,
Approximate age of all components, date installed (if known)and,source of information:
1981
Were sewage odors detected when arriving at the site? t 0 Yes ® No '
Building Sewer(locate on site plan): £
d y
r _
Depth below grade: '" 1feet
Material of construction:
❑cast iron ®40'P,VC ,❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence,of leakage, etc.):
s Piping 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: -
yearn
Is age confirmed by.a Certificate of Compliance? (attach,a copy of certificate) ❑ Yes ❑ No
Dimensions: 2000 ,gallons h
Sludge depth: 1 -
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
^ a9 Po. 9 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St. Bldg. G 4.
Property Address :
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every OSterville Ma 02655 4-9-12
page. City/Town State` Zip Code Date of Inspection
D. System Information (cont.) 1s
Septic Tank(cunt.)
31„
Distance from top of sludge to bottom of outlet tee or baffle
210
Scum thickness
Distance from top of scum to top of outlet tee or baffle
1611
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 in and oulet tee, Both covers are steal, at grade, No sign of leakage or over
loading
r
Grease Trap(locate on site plan):'-
Depth below grade: - y
feet
Material of construction:
` ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
e
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
�( 727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville Mat 02655 4-9-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal El fiberglass ❑ polyethylene ' ❑other(explain):
i
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? Q Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
727 Main St. Bldg. G '
Property Address
Wianno Knolls Condominiums ;
Owner Owner's Name
information is Osteryille Ma 02655 4-9-12 .
required for every `
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert O
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 3' Below grade with steal cover at grade, 3 lines out, No sign of over
loading or solid carry over
• ; , 4 ., ' - - , III
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes :❑ No '
Alarms in working order: ❑ Yes ❑ No
r
Comments(note condition of pump chamber„condition of pumps and appurtenances, etc.): T
Soil Absorption System (SAS)(locate on site plan; excavation notrequired):
If SAS not located, explain why: i
t5ins•11/10 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Nameinform k -
tion
required
Osterville Ma U655 4-9-12 ,.required for every •
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)' " . T
Type:
leaching pits number:'
❑ leaching chambers number:--
❑ Teaching galleries , number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
overflow cesspool number:
" ❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs•of hydraulic failure, level of pcnding, damp soil, condition of
vegetation, etc.):
Leaching is 3 precast pits, 2 in Black Top Driveway with steal covers at grade, One off driveway
with steal cover 2" below grade, Pit 2 is 3/4 full other 2 pits about 2'of 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville Mai 02655 4-9-12
page. CityrFown `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): r
Materials of construction:.
Dimensions
F
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of.ponding,condition of vegetation,
etc.): r
r .. ...� -
+ a n •
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of MassachusettsY
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments-
727 Main St. Bldg. G "
Property Address r
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville Ma" 02655 4-9-12
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
z
t5ins•11110 Title 5 Official Inspection Form:Subsurface+Sewage Disposal System•Page 15 of 17
i
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Man
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e
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K
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary p y _ ry Assessments
'• 727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville Ma 02655" ' 4-9-12 required for every '
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont:)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells T
- Estimated depth to high ground water: feet
f Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1981
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
As-Built Card f
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
t r
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St. Bldg. G
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville Ma 02655 4-9-12
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
. T .
k
t5ins-11110 v Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17