HomeMy WebLinkAbout0727 MAIN STREET (OST.) - Health (8) 727 (gig C) Main Street (Ost.) "
Osterville P
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
< � 727 Main Street(Bldg. C)
Property Address r
Wianno Knoll Condominium_ s
Owner Owner's Nam
information is Osterville MA 02655 9-28-20 required for every -...._ _ _x
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..
OF AIA
fmngoutf When
A. Inspector Information- ,
filling out forms 2; y
on the computer, '�;' JAMES•.
use only b James D.Sears the to -�• .-t=key to move your Name of Inspector ;v,
cursor-do not %�r
Robert B.Our Co. INC o o:•� g
use the return - -- - —
ke Company Name
Y.
363 Whites Path
r� Company Address
South Yarmouth MA 02664
- City/Town -- State Zip Code
/elan 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
a,47�11 �' 9-28-20
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 form should be sent to the system own`er,and copies sent to
the-buyer, if applicable, and the approving authority. F
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev:7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y Y
727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums
Owner Owner's Name
information is Osterville MA D2655 9-28-20
required for every _
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..
1) 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. Note: Outlet 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
Title 5 Official Inspection Form
_ tzSubsurface Sewage Disposal System Form Not for Voluntary Assessments
< � 727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20 _required for every -. _ _ _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
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 belowj`
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will.pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation.is Required by the Board of Health:
❑ Conditions exist.which require further evaluation by the Board of Health in order to determine if
the system is failing to,protect public health,safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street(Bldg. C)
Property Address -'
Wianno Knoll Condominiums
Owner Owner's Name information is Osteryille � MA 02655 . 9-28-20
required for eve _ .,_ '' p _._ '... -
G � every
City/Town State Zip Code Da
te ate of Inspection
C. Inspection-Summary,(coat),
❑ 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
y
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health, -
safety and environment:
❑ The system has a septic tank and soil absorption-system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a.surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.'
❑ The system has 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.
r
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® 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.7/26i201 a .. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of:18
r-
Commonwealth of Massachusetts
� -- Title 5 Official, Inspections Forrn :
Subsurface Sewage Disposal System Form - Not for Voluntary-Assessments.
727 Main Street(Bldg. CZ
Property Address
Wianno Knoll Condominiums M' _
Owner Owner's Name
information is required for every Osterville MA, 02655 9-28-20
page. City/Town State Zip Code Date-of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)'
Yes No
El ® 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 1/2 day flow P�
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.
❑ z 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. y,F
® 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 than50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at 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-
❑ ®. 10,000 gpd.
® 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.
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 C.4.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection F®rm
III Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�. 727 Main Street (Bldg. C)
Property Address --
Wianno Knoll Condominiums
Owner Owner's Name
information is e MA 02655 9-28-20 Ostervill
required for every _ _
City/Town page. Y/Town
State 4 ZipCode 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
❑ ® 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?
w
❑ ® 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? y
® ❑ 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.
0- ® 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.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
�0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street(Bldg.
Property Address
Wianno Knoll Condominiums
Owner Owner's Name
information is Osterville MA: _02655 9-28-20 _
required for every _ _ ,
page. CitylTown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms,(design): 8 Number of bedrooms (actual): 8 —
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880
Description:. 1 .:
The system is a 2000 gal. precast tank. ,D Box 3 pits." -
Number of current residents: NA
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 Z No
information in this report.)
Laundry system inspected? ❑ Yes Z No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): NA
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Present,_
Date
t5insp.doc•rev.7/2612018 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street(Bidg_C)
Property Address
Wianno Knoll Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every
page. Cityfrown 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 to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Yearly Pumping- --- ---- i
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons _.
How was quantity pumped determined? -
Reason for pumping: — -
t5insp.cloc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street (Bldg. C) T
Property Address
Wianno Knoll Condominium_ s _
Owner Owner's Name
information is Osterville _ _MA 02655 9-28-20 required for every _ ___•
page. City/Town State . Zip Code Date of Inspection
D. System Information: (cont.)
4. Type of System:
® Septic tank; distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared'system (yes or no) (if yes, attach previous inspection records, if any)
0 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.
y ❑ 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
51. Building Sewer(locate on site plan):
Depth below grade: 4'
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.)`
Piping is 4' SCH 40 PVC.
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
.. A
Commonwealth of Massachusetts
Title 5 Official Inspection -Form
lip Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L!j 727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums
Owner Owner's Name -
required for every information is Osterville MA 02655 9-28-20
require _ _ _
page. City/Town State . Zip Code Date of Inspection
D. System Information (cont.)
6. Septic-Tank(locate on site plan)`
3,
Depth below grade: - feet
-Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene [-]'other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy Fof certificate). ❑ Yes ❑ No
I - - .
Dimensions: � � --2000, al -
2
Sludge depth:
Distance from top of sludge to;bottom of outlet tee or baffle 28 --
.. 211
Scum thickness
8
Distance from top of scum to top of outlet tee or baffle -
Distance from bottom of scum to bottom of outlet tee or baffle 1611
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 w%inlet Tee inlet. Both covers steel at grade no sign of leak age or over
loading.
- , -
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
V � 727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums
Owner Owner's Name —
information is
required for every Osteryille _ MA 02655 9-28-20
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 constructions
❑ 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
aq .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
rI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street(Bldg. C) -
Property Address
Wianno Knoll Condominiums
Owner Owner's Name
information is Osterville _ MA 02655 _ 9-28-20
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
" Alarm present: ❑ Yes. ❑ No
Alarm level: -- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date .
Comments (condition of alarm and float switches, etc.):
"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
Comments (note if box is level and distribution to outlets equal, any evidence'of.solids,carryover, any
evidence of leakage into or out of box, etc.):
D Box is clean and solid. 30"Below grade w/steel cover at grade 3 lines.out. No sign of over
loading or solid carry over.
t5insp.doc-rev.7/26i2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
i
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�I Subsurface Sewage Dis osal S stem Form -Not for Voluntary Assessments
9 p
y � rY
727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums
Owner Owner's Name w.
information is Osteryille MA 02655 9-28-20
required for every _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):.
Pumps in working order: ❑ Yes. ❑ No*
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: ------ --
❑ ieaching,galleries number:
❑ leaching trenches - number, length:
❑ leaching fields number, dimensions: —
❑ overflow cesspool number.. --- --- —
❑ innovative/alternative system
Type/name of technology: — ---
t5insp.doc•rev.7/26.12018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1�: Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums k z
Owner Owner's Name
information is Osterville MA 02655 9-28=20 a
required for every
page. City/Town State` Zip Code Date.of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is 3 precast pits with steal covers at grade. Pits 34 Dry. Pit 2 Full.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan).
Number and configuration --
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer -
Dimensions of cesspool
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.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
f
Commonwealth of Massachusetts
- , Title 5 Official Inspection Form
!1,I1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f� -
,` 727 Main Stree (Bldg C)
Property Address
_Wianno Knoll Condominiums
.Owner Owner's Name
information is Osteryille MA_ 02655 _ 9-28-_20
required for every _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions -- --
Depth of solids
Comments (note condition of soil, signs of•hydraulic failure, level of ponding, condition of vegetation,
etc.):
•
t5insp.00c•rev.7/25/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 18
I '
CommonweaCCth of Massachusetts
- , Title 5 Official Inspection Form
�1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 727 Main Street(Bldg. C)
Property Address
Wianno Knoll Condominiums`
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every _-_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below: F
'E] hand-sketch in the area below
® drawingattached separately
se p Y
h _
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
'n ,1P Title 5 Official Inspection Form
- _ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�C � 727 Main Street(Bldg. C) _
Property Address
Wianno Knoll Condominiums
Owner Owner's Name
information is 02
Osterville MA 655 9-28-20
required for every _ _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
®Check Slope
® Surface water
® Check cellar
❑ -Shallow wells
N0
Estimated depth to igh ground water: 12 +
feet
Please indicate all methods used to determine the high ground water elevation:
® ' Obtained from system design plans on record
981
If checked, date of design'plan reviewed: _Date
Observed❑ Observed site(abutting property/observation hole within 150,feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators; installers-(attach documentation)
❑ Accessed USGS database -explain:
You must.describe how you established.the high ground water elevation:
--Per Design
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc rev.7/23/2018 F Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection , orm
�. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�< � 727 Main Street (Bldg. C)
Property Address
Wianno Knoll Condominiums-
Owner Owner's Name - - -
information is
required for every _O_steryille 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. Inspectorinformation: Complete all fields in this section.
B. -
Certification:,Signed & Datedan d123 r4 o checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
A
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
J£
N0
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
f
Commonwealth of Massachusetts
g Title 5 official Inspection Form
VIO,
I' Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner owner's Name
information is psterville
required for every MA 02655 5-14-18
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: n A. General Information filling out forms 67/# /3��l.. `�attuuufi�r� r�
on the computer, `(�' �����
use only the tab 1• Inspector. `����,�H Of Mgss9%��
key to move your
cursor-do not James D.Sears _ g: • JAM ES G
use the return Name of Inspector m
key. :
Ca wide Enterprise �* #a`
Q Company Name
��i ! ••.. 1 ��
153 Commercial Street
Company Address
Mashpee
CitylTown MA 02649
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
5-15-18
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 conditlons 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.Aoc•rev_6/16. '
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
66 a5ed XeA dH 99:£Z 860Z 96 XeW-
1
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Ostervllle
required for every MA 02655 5-14-18
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:
® 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.
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):
i
t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•?age 2 of 17
0Z a5ed xed dH L5U RU 96 XeW
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02656 5-14-18
page. cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumpslalarms 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 ❑ NO(Explain below):
I�
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR.
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6116
T t!e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 or 17
6Z a5ed xe:1 dH 89:£Z 860Z 91• XeW
Commonwealth of Massachusetts
U1 Title 5 Official Inspection Form
io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V% 727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
owner Owner's Name
information is required for every QSterVllle MA 02665 5-14-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
E ® Liquid depth in 4110=is less than 6" below invert or available volume is less
than '/z day flow p,T;S
t5ine.doc rev.611E Tide 5 Official Inspection Form:subsurface sewage Disposal System,Page 4 of 17
ZZ a5ed xez] dH K£Z 860Z 96 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�p
u
727 Main Street(BLDG C)
ki Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
per. City(rown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOTdue 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.
❑ z The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 16.303, 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,
15ins.doc-rev.6116 Tide 5 Official trvspection Form:Subsw1ace Sewage Disposal System,Page 5 of 17
EZ a5ed xed dH 89U 860Z 91, AeW
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
! Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is OSterville
required for eve MA 02655 5-14-18
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built.plans of the,system obtained and examined?(if they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health,
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880
t5ins.doc•rev.6116 Tale 5 Official Inspection Forth:Subsurface Sewage deposal SYstam•Page 6 of 17
tiZ a5ed xed dH 69U 91,0Z 91, AeW
Commonwealth of Massachusetts
rTitle 5 Official Inspection Form
v
N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
page. City/rown State Zip Code Dale of Inspedian
D. System Information
Description:
2000 Gal. tank , D Box 3 pits.
Number of current residents: NA
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
CommerciaVindustrial Flow Conditions:
Type of Establishment
i
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seatslpersons/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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
`yZ a5ed xed dH 69U 860Z 91, AeW
Commonwealth of Massachusetts
12 Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is
required for every Osterville MA 02656 5-14-18
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: na
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins.doc•rev.6116 T;tle 5 official Inspection form:Subsurface Sewage Disposal System•Pape 8 or V
gZ a6ed xed dH 00:00 860Z L6 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
MMF
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02665 5-14-18
page. Cityf town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan).
Depth below grade: 4'feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" SCH 40 PVC
Septic Tank(locate on site plan):
Depth below grade: 3"
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 2000 Gallons
Sludge depth:
Nnsboc-rev.6118 Title 5 Official Inspection Form:Subsurface sewage Disposal System•page 9 d 17
LZ abed xed dH 00:00 860Z LI• AeW
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required For every Ostervllle MA 02655 5-14-18
page, City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Plan -TapeSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level with/in and outlet Tees . Cover steel at grade.No sign of leakage or over
loading.
Grease Trap(locate on site plan):
Depth below.grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.SM6 Title 5 Official Inspection Form:Subsurface Sewage Dispose)System Page 10 of 17
gZ a5ed xed dH 00:00 8 60Z L l, 42W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions;
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level:_ Alarm in working order: ❑ Yes ❑ No
Date of last pumping: bate
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc rev.6/1e Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of W
6Z a5ed xed dH 1,0:00 860Z Ll, 4eW
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
.�' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y 727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is
Cisterville MA 02655 5-14-18 ,
required for every `
page, Citylrown State Zip Code Date of Inspection
D. System Information (cost.)
7
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is clean and solid 30" below grade. 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.doe-rev.SAS Tltle 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
OE abed xed dH 60:00 860Z ,LI, XeW
f
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
page. City1rown State Zip Code Date of Inspection
D. System Information (cost.)
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 with steel covers at grade. Pits 3-4 have 1'water. Pit 5-6" 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
t51na.doc-rev.6116 Title 5 Official Inspedion Form:Suhsurfeoe Sewage Disposal System-Pogo 13 of 17
�� a5ed xed dH 10:00 860Z Ll• !eW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iws Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
page. CityrTown 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.):
151ns,doc rev.W S Title 5 OfAcW Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Z£ a5ed xezl dH Z0:00 860Z LI 4eW
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
page. Cityrrown State Zip Code Date of Inspection
D. System information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
15ins.doc rev.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 15 of 17
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ti£ a5ed xed dH ZOi00 860Z L6 AeW
Commonwealth of Massachusetts
qTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.
727 Main Street(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA C2655 5-14-18
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
NO
Estimated depth to h ground water: 12'+
hig
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 propertylobservation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per Design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins.doc•rev.6116 Title 5 Offeiat Inspection Form:Subsudwe Sewage Disposal System•Page 16 of 17
5£ a5ed xe:1 dH Z0:00 8602 LL XeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street�(BLDG C)
Property Address
Wianno Knolls Condominiums
Owner Cwvners Name
information is required for every Osterville MA 02655 5-14-18
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins.doc rev.6116 Tillie 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 17 of 17
96 a5ed YU dH £0:00 860Z Ll• AeW
Commonwealth of Massachusetts4'
Title 5 Official Inspection Form L/ 1 -6 t 5 Doc
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments O /3-- 0
727 Main St.Bld . C
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
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms `` �N OFf„h,,,,,,
on the computer, Cr �� �. Ss,,. f-
1
use only the tab 1. Inspector: �41
key to move your O • .. •'•yG
cursor-do not James D. Sears _ JAMES :m
use the return — ' -t=
key.
Name of Inspector =L) :t»
Capewide Enterprises,LLC ��•.
Company Name
153 Commercial Street I
Company Address
Mashpee Ma 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have.personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Q1 4-15-15
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 futu under
the same or different conditions of use.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St.Bldg. C i
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. CityfTown 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.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M s•`�< 727-Main St.Bldg. C
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.)
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):
3
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St.Bldg. C
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.)
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 eacWW is less than 6" below invert or available volume is less
than 'h day flow P/
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Cityrrown State Zip Code Date of Inspedion
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 li 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 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Insp
ection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , ' 727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner Owners Name
information is required for every Osterville MA 02655 4-15-15
page. CityrFown 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)
N . ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880
t5ins-11/10 Title 5 Official Inspection 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 y 727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner owner's Name
information is required for every Osterville MA 02655 4-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 2000 gal precast tank, D box 3 pits.
Number of current residents:
NA
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required]. ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
x
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage NA
9 ( Y 9 fgpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease 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
sp 727 Main St.Bldg. C
M °
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 0 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 St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site?' ❑ Yes ® No
Building Sewer(locate on site plan): '
Depth below grade: 4'
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" SCH 40 PVC.
Septic Tank(locate on site plan):
Depth below grade: �31
et
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
2000 gallons
Dimensions:
Sludge depth: 21-
t5ins•11/10 Title 5 Official Inspection Farm: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
w 727 Main St.Bldg. C
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 (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
I
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Plan Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level with/inlet Tee inlet cover,Cover steel at grade. No sign of leakage or over
loading.
Grease Trap(locate on site plan):
Depth below grade:. feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11110 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. C
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
ID. 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.):
s
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth, of Massachusetts
Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osteryille MA 02655 4-15-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is clean and solid. 30" below grade,with steel cover at grade 3 lines out. No sign of over
loading or solid carry over.
4
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required): .
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
o Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 with steel covers at grade. Pits-34 Have 2'Water. Pit-5 Dry.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 727 Main St.Bldg. C
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.)
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
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Cityfrown 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
Page 1 of 2
Town of Barnstable Geographic Information System
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main St.Bldg. C
Property Address
Wianno Knolls Condominiums
Owner owner's Name
information is required for every Osterville MA 02655 4-15-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)-
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
/V®
12'+
Estimated depth t high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1981
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
® Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per Design Plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St.Bldg. C
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
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
Z
EXECUTIVE OFFICE OF.ENVIRONMENTAL AFFAIRS
rA
c DEPARTMENT OF ENVIRONMENTAL PROTECTION
M
350 MAIN STREET
WEST& 08 775-28000UTH, MA 3Y3-'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A J J
CERTIFICATION
MAP 141 PAR 013
PROPERTY ADDRESS: 727 MAIN STREET, OSTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: JANUARY 18,2000 WIANNO KNOLL CONDO
NAME OF INSPECTOR : JULY 20, 2006 ' °, BUILDING C
I am a DEP approved system inspector pursuant to Section1 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 ;
TELEPHONE NUMBER: - (508)775-2800 7
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: DATE: JULY 24,2006
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the
system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. =,
NOTES AND COMMENTS: BLDG. C
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME 1 �
OF THE INSPECTION.THERE IIS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
CD
G Y
C7)
revised 9/2/98 1
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO, BUILDING C
Date of Inspection: JULY 20, 2006
INSPECTION SUMMARY: Check A,B, C, orD:
A] SYSTEM PASSES: X
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO-BUILDING C
Date of Inspection: JULY 20, 2006
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS.is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
L
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO-BUILDING C
Date of Inspection: JULY 20, 2006
D] SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged .
SAS or cesspool.
X Discharge or ponding of effluent.to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
X Liquid depth in pits is less than 6"below invert or available volume is less than'%day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
N/A Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
N/A Any portion of a cesspool or privy is within a Zone I of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or
mapped Zone 11 of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO
Date of Inspection: JULY 20,2006
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex..Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)[15.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JULY 20,2006
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 880 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 8 Number of bedrooms(actual): 8
Total DESIGN flow N/A
Number of current residents: N/A
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): YES
Seasonal use(yes or no) NO
Water meter readings,if available(last two(2)year usage(gpd):
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COM M ERCIAUI NDUSTRIAL:
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NOTE:MAINTENACE PUMP AFTER INSPECTION.
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of D E P Approval
Other
APPROXIMATE AGE of all components, date installed (if known)and source of information:
1984 BARNSTABLE HEALTH DEPARTMENT, 1998 NEW D-BOX PERMIT#98-104
Sewage odors detected when arriving at the site:(yes or no) !�`�
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BULDING C
Date of Inspection: JULY 20, 2006
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(Locate on site plan)
Depth below grade: 44"
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 2,000 GALLON
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How dimensions were determined PLAN&TAPE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET TEE,INLET COVER STEEL AT GRADE. OUTLET COVER 44"BELOW GRADE.DID NOT
OPEN.NO SIGN OF LEAKAGE OR OVER LOADING.
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
Material of construction concrete metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JULY 20,2006
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D-BOX IS 16"X16",T BELOW GRADE,ONE LINE IN,THREE LINES OUT.BOX WAS REPLACED IN 1998 PERMIT#98-104.
NO SIGN OF LOADING OR SOLID CARRY OVER.
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JULY 20,2006
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 3
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
PIT(1)5'BELOW GRADE,SPIT,20"WATER. PIT(2)4'BELOW GRADE,SPIT,8"WATER. PIT(3)6'BELOW GRADE 6'PIT
8"WATER. ALL PITS HAVE STEEL COVERS AT GRADE.
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO-BUILDING C
Date of Inspection: JULY 20, 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 1 00'(locate where public water supply comes into house)
SEE ATTACHED PLAN.
i_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JULY 20, 2006
MRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to no groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE: PLAN ON FILE AT BOARD OF HEALTH, 12' NO GROUND WATER—SITE HIGH.
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4 RECEIVED
JUL 16 2003
COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE
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EXECUTIVE OFFICE OF ENVIRONMENT HEALTH DEPT.
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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350 MAIN STREET
WEST YARMOUTH,MA
508-775-2800 '
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 141 PAR 013
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner's Name: WIANNO KNOLL CONDOMINIUMS
Owner's Address: PO BOX 1073
OSTERVILLE,MA 02655
Date of Inspection JUNE 25,2003
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
1 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 perfonned based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
./ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority.
Notes and Comments
****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.
C
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ✓
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6115/2000 2
Page 3 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to detennine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title S Inspection Form 6/15/2000
P _ 3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pits is less than 6"below invert or available volume is less than '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone I of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM R 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping infonnation was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
J 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 scram
✓ Was the facility owner(and occupants if different from owner)provided with infonnation on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing infonnation. For example,a plan at the Board of Health.
✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6!15/2000 5
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
FLOW CONDITIONS
RESIDENTIAL-CONDOMINIUMS
Number of Bedrooms(design): 8 Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 880
Number of current residents: N/A
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM R 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: ANNUAL PUMPING
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detennined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes;attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1984,NEW DISTRIBUTION BOX IN 1998 PERMIT#98-104
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 44"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 2,000 GALLON
Sludge depth: 3"
Distance from top of sludge to the bottom of outlet tee or baffle: N/A
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions detennined: PLAN AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL.INLET TEE,INLET COVER STEEL AT GRADE.OUTLET COVER 44"BELOW
GRADE. DID NOT OPEN.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: e concrete e metal fiberglass _ polyethylene other.
(explain):
Dimensions:
Scorn thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Fotm 6/15/2000 7
Page 8 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS 16"xl6",Y BELOW GRADE.ONE LINE IN,THREE LINES OUT. BOX WAS
REPLACED IN 1998.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6,115/2000 8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 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.)
PIT(1)5' BELOW GRADE,5'PIT T WATER.PIT(2)4'BELOW GRADE,5' PIT, 18"WATER.PIT(3)
6' BELOW GRADE,6'PIT, 10"WATER.ALL PITS HAVE STEEL COVERS AT GRADE.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title-5 Inspection Forin 6%15/2000 9
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET—BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Title 5 Inspection Form 6/15/2000 10
Page 11 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING C
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
./ Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TEST HOLE ON PLAN.NO WATER AT 12'.
Title 5 Inspection Form 6i 1512000 11
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
IM ^
DATA
I
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=( _- COMMON WEAL I J I OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMEN`I'A.L AFFAIRS
DEPARTMENT OF ENVIRONMENTAL. PROTECTION
ONE WINTER STREF..T, BOSTON MA 02108 (617) 292-5500
TRUDY COXF,
350 MAIN STREET Secretary
ARGEO PAUL CELLUCCI WEST YARMOUTH, MA DAVID B. STRURS
Governor 508-775-2800 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART A
CERTIFICATION
MAP 141 PAR 013
PROPERTY ADDRESS: 727 MAIN STREET, OSTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: JANUARY 18, 2000 WIANNO KNOLL CONDO
NAME OF INSPECTOR : JAMES D. SEARS BUILDING C
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: DATE: FEBRUARY 2,2000
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the
system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS: .
SITE OVER ALL PASSES,INSPECTION OF.SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. a
v QiM'
-
'
revised`,9/2/98 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO, BUILDING C
Date of Inspection: JANUARY 18,2000
INSPECTION SUMMARY: Check A,B, C, orD:
A] SYSTEM PASSES: X
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_ The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
I
i •
revised 9/2/98 2
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET,OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
,
Date of Inspection: JANUARY 18,2000
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC'HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has aseptic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
.revised 9/2/98 3
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 727 MAIN STREET,OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JANUARY 18,2000
D]SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required)pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or
.mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO
Date of Inspection: JANUARY 18,2000
k
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have-not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and.examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance its unacceptable)11 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
Y
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 727 MAIN STREET,OSTERVILLE
Owner: WIANNO KNOLL CONDO-BUILDING C
Date of Inspection: JANUARY 18,2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 880 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 8 Number of bedrooms(actual): 8
Total DESIGN flow N/A
Number of current residents: N/A
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): YES
Seasonal use(yes or no) - NO
Water meter readings,if available(last two(2)year usage(gpd):
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industria6 Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
YEARLY PUMPING
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known)and source of information:
1984 BARNSTABLE HEALTH DEPARTMENT, 1998 NEW D-BOX PERMIT#98-104
Sewage odors detected when arriving at the site:(yes or no)
-revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO-BULDING C
Date of Inspection: JANUARY 18,2000
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(Locate on site plan)
Depth below grade: 44"
Material cf construction X concrete metal Fiberglass Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 2,000 GALLON
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How dimensions were determined PLAN&TAPE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET TEE,INLET COVER STEEL AT GRADE. OUTLET COVER 44 BELOW GRADE.DID NOT
OPEN.
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: `
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET
Owner: WIANNO KNOLL CONDO-BUILDING C
Date of Inspection: JANUARY 18,2000
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.) `
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: 0 .
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D-BOX IS 16"X16",3'BELOW GRADE,ONE LINE IN,THREE LINES OUT.BOX WAS REPLACED IN 1998 PERMIT#98-104.
PUMP CHAMBER: N/A ,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JANUARY 18, 2000
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 3
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
PIT(1)5'BELOW GRADE SPIT,3"WATER. PIT(2)4'BELOW GRADE,5'PIT,6"WATER. PIT(3)6'BELOW GRADE,6'PIT,
2"WATER. ALL PITS HAVE STEEL COVERS AT GRADE.
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) "
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions: .
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JANUARY 18, 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM: `
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
SEE ATTACHED PLAN:
t
revised 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING C
Date of Inspection: JANUARY 18, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to no groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE: TEST HOLE ON PLAN; NO WATER AT 12'.
revised 9/2/98 11
- 1
LOCATION SEWAGE PERMIT NO.
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VILLAGE:
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IN/ST{Ai LLER'S NAME i ADDRESS
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BUILDER OR OWNER
\A/ I.,=. , , :[X D .5�
Dar? Ma sT, cN-cT Y 2�� 11Q,T� asx.
DATE PERMIT ISSUED � z-88o
DAT E COMPLIANCE ISSUED
i
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� THE COMMONWEALTH-OF MASSACHUSETTS
BOARD OF HEALTH
".,ej.............OF........
.....-
Appilration for Disposal Works Tonotrnrtion Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......... c31.h....�/....=---• .......................
......---------------------
---- --.----,--------.......�............ �,..�..............................
• P tion-Add ss + r No. +0
? ? . ..... ..................................: z ...�1 a .............................................�� ti
Owner dr
��:......./ - ---- -- --------------- Y �_..... ....................................................
Installer Address 9� �t�
Type of Building Size Lot_._a____ _________________Sq. feet
U Dwelling=No. of Bedrooms.......... ...........................Expansion Attic ( ) Garbage Grinder ( )
'PL44 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ............................ .
-------------------------------
W Design Flow_____________ ..........,..._._gallons per person peer cy. Total daily ow.................... .._..... ......._..galloz}s.
WSeptic Tank—Liquid capacityl� gallons Length------- .__._ Width_:_...�.... Diameter..................Depth..... .........
x Disposal Trench—No. -..-.--_------_--- Width.................... Total Length.................... Total leaching area....................sq. ft.
.lam 4?... Depth below inlet-___ _ ... Total leaching area ...s ft.
� Seepage Pit No..................... Diameter._. _...___.__. p g q.
Z Other Distribution box (p<) Dosing t k ,
''•' Percolation Test Results . Performed by... C+- ... ....................... " Date....... -_.....�Q_
----------- - -
14 Test Pit No.14....A....minutes per inch Depth of Test Pit-___j Z....... Depth to ground water.._ .....
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit................... Depth to ground water-___--_____._-___--.--_.
--------------- -------• ... ..
O Description of Soil ` -----G v �,a` �8 e/---- �
x
W
VNature of Repairs or Alterations—Answer when applicable_____________________________--____--.-..-_--.-_-__--_•-_-_______--_____----___-_-__-..---.___.
...----•-•---- ••••-•---•--•••-•--•-•••-•--••--•----•-•--••••--•----••-•••--•••-•-•...................•--••••-••---•---••--------•-•----••----••-----•-•••--•-••--••-•••-•••......-••-••-•--•-..........
gree ent:
e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
t pr i ions of'ITLi: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
ion until a Certificate of Compliance has been issued by the board of health.
................................
igned--•-• -.ram ---------------•--•
D to
- -Pli Approved By-. :_ ... 12-
Date
tr)U pplKK
i ff' Disapproved for the following reasons:----•-•...---••-••-•-----•-••-•--•-••---------------••-------•••••••--•-••••---•---•---------•--•-••---•------
FGlS.r� `yam -----•----------------•---------..._....._--•-----•----------•---•----...-Date..............
SSIONIA EEC
PermitNo......................................................... Issued-.......................................................
Date
N Ql. FEB. .... ... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............OF..........� rS d _� ...............
Applirtttion for Disposal Works Touift.rurtinn ramit
Application is hereby made for a Permit to Construct (, ) or Repair ( ) an Individual Sewage Disposal
System at: �,-
..........t' . . . ----•............................. ................................................. ...........................................
t
r1ion-Addr ss t or No `
- ------- ------ - y
Owner r�+ '� ,/✓, d gg
�..e.: A.w. ...... . ...... ij'e'+_../._.. �#� .....--•..............•-- --•--
.Installer Add-ess 1
dType of Building Size Lot__ .................Sq. feet
Dwelling—No. of Bedrooms........... ____________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons___________________________ Showers — Cafeteria
d )Other fixtures ._-----••-------_. ---•- ----------------------------------
-----•-----•• -_------
W Design Flow__...__..____.................gallons per person per d y. Total daily fbw.................... .........gallons.
WSeptic Tank—Liquid capacity,/4'1'2kallons Length_____:�`-.-_-• Width.......JC.... Diameter________________ Depth...... :._..
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area________________._.sq. ft.
Seepage Pit No.......0L--------- Diameter.___ ___ Depth below inlet____ '_=9... Total leaching area...4 ...sq. ft.
Z Other Distribution box O Dosing tank :.
Percolation Test Results Performed by.___ _L..,.._,. .4-'. LJI__ ___________ Date____. '�
,.., ,� t... U
a �p� ••-
,� Test Pit No. .. .____minutes per inch Depth of Test Pit----1_�_______ Depth to ground water_____ __ ______�-
ti, Test Pit No.-2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
a q
D Description of Soil..... f ---- .. tl ¢ Yd
-----------••-----------------•-------------•--------------
U --••--•----------- -------------------------------- -_-•----•- ___---•------------•-----_ ------------------------
W
UNature of Repairs or Alterations—Answer when applicable__:.- _________________________________....___.__.___.__.___......_._...____.________________..
t
...............•-••-•••••••....................••••-•-•••••••••-••--•-••••-•-•••_--................__.........-•-•••----------••-•-••••---•••••....-•••••••••-•-•••-••••-•••-...••••••••--•••-.....•••.
gree ent:
e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
"ons of TITITE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
ntil a Certificate of Compliance has been issued by the board of health.
s �N i ned_ .................................
g - .ter_-,.��.,r.__- �-'-�-'"��. ------- ...................UTWWI6( D to
l scat dfi pProved By.._.. Y... _ .........................'
___...•••--•-•-._Date•••-•-
Disapproved for the following reasons------------------•--=--•---.._..------------------------------••----------- ....._
Date
PermitNo—_..................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF....... _.._....._ .................... I
C�rr�i�irtt#r ,a� f�unt��itt�trr
THIS IS TO CERTIFY, That the R vidual age Di osal System constructed or Repaired ( )
,,.
by- :"'. ° - - - ------------------------------•--------.......---......._..•••-••-...._••-•-•--
V In taller
at ----•--••-- -----------------------------------------------•-------•-------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. o___. .__ _�+_________ datec _____________________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL ®T BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFA TORY.
DATE. � --------------
Inspector........:. _1. �!_ S'.... .......................................
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,/ C+r
,r2,a>•*.:...,......... swa+�n.i<rf ........
No . d s .�► FEE---. . ..........
Permission is hereby granted............. ---A� ------------- `t'j--t--r •• L4Z-------'A-•---•......--- ............
- to.,Construct ( �r Repair ( ) an Individual
Sewa e Disposal System
Street
as.shown on the application for Disposal Works Constructio it No_____________________ Dated__ _.._.._.___... ._._......
..................
• as'
Board of b^
DATE rS, ' ..::.. :.......................
FORM 1: 5 -HoeBs & WARREN, INC.. PUBLISHERS
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