HomeMy WebLinkAbout0727 MAIN STREET (OST.) - Health (9) ell
.727 (Blg B) Main Street (Ost )'
Osterville P i
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Commonwealth of Massachusetts /y/— 0/3- 004
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I� Title; 5 Official Inspection Form
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Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4-,
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727 Main Street (Bldg B)
Property Address ',
Wainno Knolls 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 I k)
INI
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.
````��jN OF
Important:when A. Inspector Information 5�# /q 3 �`'��• qc
filling out forms $�r
on the computer,
JAMES s
1 S D. ears
use only the tab. James —
key to move your Name of Inspector = a
cursor-do not Robert B.Our Co. INCH'•=
use the return — -- - — ---- '�' F T tea .
ke . Company Name !�c •.. � `��•
y 363 Whites Path r+r 5 INS?' \N�
r� Company Address
South Yarmouth _ MA 02664
City/Town State Zip Code
rr� 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 MR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
_ 9-28-20 _
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection; If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority. .
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
e Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street (Bldg B) f
Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20 i
required for every -----
page. City/Town State t Zip Code bate of Inspection
C. Inspection Summary'
Inspection Summary: Complete 1;2, 3,.or 5 and all of 4 and 6.
1) System Passes:. .
® I,have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a1500 Gal. Tank and 2 pit's Note:Tank 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. 1
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please'ezplain.
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,iess 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 "
lip
Title 5 Official Inspection Form
- I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
........... 727 Main Street (Bldg B)
emu— —
Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is '
required for every Osteryille _ MA 02655'.> 9-2$-20
page. Cityrrown 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" El '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 ❑ 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 18
Commonwealth of Massachusetts
Title 5 Official ' Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
...........�V!% 727 Main Street (Bldg B)
Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every -- -
page. Cityrrown State Zip Code -Date of.Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or'privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will,fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety;and environment:
❑ The system has 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 aseptic 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 thisform. e
c. Other:
f
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
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Commonwealth of Massachusetts i
�m ,p Title 5 Official, Inspection Form
w
+, i. Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
727 Main Street (Bldg B) _
Property Address _.
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville k MA . 02655 9728-20
required for every -- -
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary-(cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
mYes No ,
❑ ®:° Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool .
❑ Liquid depth in amnsped is less than 6" below invert or available volume is less
than 1/2 day flow P,7"
Required pumping more than 4 times in the last year NOT due to clogged or
® obstructed pipe(s)_ Number of times pumped:
.❑ `� Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well. .
❑ ® Any portion of a cesspool or.privy is within 50 feet of a private water supply well,
❑ 0. Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet
from a private water supply well with,no acceptable water quality analysis, [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A'copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving.a facility with a design flow of 2000 gpd-
® 10,000 gpd.
ED ® The system fails. I have determined that one or more of the above failure
criteria exist as described in310 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 alarge system the'system must serve a facility with a
design flow of 10,000 gpd to .15,000 gpd.
For large systems, you.must'indicate either."yes".or"no"to.each of the following, in addition to the
questions in Section CA. `
Yes: No
El ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—1WPA)or a mapped Zone II of a public water supply well
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ie Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
727 Main Street (Bldg B)
Property Address
Wainno Knolls 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 jcont.)
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?
Have large volumes of water been introduced to the system recently or as part of
El ® this inspection?
® El Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of breakout?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑' Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•irev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V0 727 Main Street (Bldg B)
Property Address
Wainno Knolls 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
1. Residential Flow Conditions:
Number of bedrooms (design): 4 - Number of bedrooms (actual):
4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd z#of bedrooms):
440
Description:
The system is a 1500 Gal. precast tank and 2_ its. _
Unknown
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Z No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to: ---Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ 'Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy. Date
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts-
Title 50
Offici
al Inspection
ction Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
cJ� _727 Main Street (Bldg B) _-
r� Property Address
Wainno Knolls Condominiums _
Owner Owner's Name
information is Osterville MA 02655 _ 9-28-20
required for every
page. Cityrrown 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(9Pa
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
3. Pumping Records:
So Yearly Pumpingurce of information: b --�
Was system pumped as part of the inspection? ❑-,Yes ® No
If yes, volume pumped: gallons.
How was quantity pumped determined? .
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts r
Title 5 Official Inspection Form
' Fig Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
c !' 727_Main Street (Bldg B
u Property Address
Wainno Knolls 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.)
4. Type of System:
® Septic tank, distribution box, soil.absorption system
El Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)*
❑ Innovative%Alternative technology. Attach a,copy of the current operation and
maintenance contract(to be obtained-from.system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other.(describe):
Approximate age of all components, date installed (if known) and source of information:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
2.6'
Depth below grade: feet
Material of construction:
❑ cast iron ®4.0 PVC ❑ other(explain): --- --------
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Piping is 4" SCH 40 PVC.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
II
•q r
Commonwealth of Massachusetts '
Ip Title 5 Official Inspection Form
' Fig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street (Bldg B)
Property Address
Wainno Knolls 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.)
6. Septic Tank(locate on site plan):
DeDepth below-grade: 2'.
pfeet
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: 1500 Gallon
Sludge depth:
Distance from top of sludge to bottom of outlet tee.or`baffle
29"
» 2"
Scum thickness —
Distance from top of scum to top of outlet tee or baffle
8"
1611
Distance from bottom of scum to bottom of outlet tee or baffle -
How were dimensions determined? Plan Tape
Comments (on pumping recommendations,_.inlet and outlet tee or baffle condition, structural integrity,
liquid levels as'related to outlet invert, evidence of leakage, etc.):
Tank at working level w/inlet Baffle Steel cover 6" below grade. No sign of over loading or solid carry
over outlet tee w/filter.
t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
1
Commonwealth of Massachusetts
Title 5 Official_ Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
cam !% 727 Main Street (Bldg B).
u Property Address
Wainno Knolls 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.)
7. Grease Trap (locate on site plan):
Depth below grade: r 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 r
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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 1a
C� Commonwealth of Massachusetts
{ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. p Y
727 Main Street (Bldg B)
Property Address
Wainno Knolls Condominiums _ _—
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every - --- --
Zip Code Date of Inspection
page. City/Town State
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 No D Box
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.):
t5insp.doc•rev.7126/201.8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
4;
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�r
. r (Bldg,B
7 Main Street
72 ( 9 ) -- -
`-' Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
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:
2
❑ leaching chambers number:
❑ leaching galleries number:
k
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: -- _ -
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts m
- Title 5 Official Inspection:Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ems !% 727 Main Street (Bldg g)
Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every Cit !Town State Zip Code Date of Inspection
page. Y
D. System Information_(cont ) 4_
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 2 pits in line. First pit has outlet tee. First pit water level at tee.2"d pit U to water,No high
stain line.;Both pits have,steel covers at grade.
12. Cesspools (cesspool must be pumped as'part of inspection) (locate on site plan):
Number and configuration o
Depth—top of liquid to inlet invert
Depth of solidslayer
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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form - '
Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments
F
727 Main Street (Bldg B)
Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required
ge. for every City/Town State Zip Code Date of Inspection'
D. System Information (cont.)
13. Privy{locate on site plan):
P
Materials of construction:
Dimensions
Depth of solids --
Comments{note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.-):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
F Title 5 Official, Inspection. Form
�. iIb Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
Vie, ! 727 Main Street (Bldg
Property Address
Wainno Knolls 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:
Fl hand-sketch in the area below
drawing attached separately
x
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
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C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` c,�� 727 Main Street (Bldg-B)
Prop®rty Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 9-28-20
required for every ---
page. Cityrrown. State Zip Code Date of,inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
- Z-.Check cellar
❑ Shallow wells
wv r
12"+
Estimated depth to g ground water: feet
.E -
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
1771 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.
t5insp:doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� , Di Form Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments
, f I m!� 727 Main Street (Bldg B) -
Property Address
Wainno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 `9-28-20
required for every — --
page. City/Town State Zip Code Data of Inspection
E. Report Completeness Checklist:
Complete'all applicable sections of this form inclusive of:
® A.,Inspector:lnformation: Complete all fields in this section.{
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure.Criteria) and 6 (Checklist)completed
® D.System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16.or attached
For-15: Explanation of estimated depth to High groundwater included
1 T-�
® 07
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t5insp.doc-rev,7/26/2018 - - Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�4 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street BLDG B
Property Address
Wianno Knolls Condominiums
Owner owner's Name
information is required for every OSterville MA 02665 5- 14-18
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms 3 a �tttturmurur�r��
use only the tab on the r �J" ✓ `� 0.L(H OF
1. Inspector .���4
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Ca wide Enterprises
VQCompany Name �%
153 Commercial Street g4ipF 5 I N SP�G������
Company Address
Mashpee MA 02649
CrtylTown 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. 1 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 V
4;4,
spector's Signature Date
The system inspector shall submit a copy of this inspection report'.to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10„000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
`"""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 THIa 5 Official Inspection Form:Subsurface$CWiQi(]IS'Kll$yStMl 'ig1 1 i(1T
@fed RJ dH ZS:£Z 860Z' 96 XeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
C Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5- 14-18
page. CitylTown 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 1500 Gal. Tank and 2 Pit's
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins.doc rev.W6 Title 5 Wrist Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Z a5ed xeJ dH 29U 81,0Z 91, A2W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iy Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Fr ,
727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
owner Owner's Name
information is required for every OSterVllle MA 02655 - 5-14-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) ,
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y
❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N below):lain ND Ex❑ ( p o ).
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C,) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health. safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins.doc rev.6116 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposer System•Page 3 of 17
£ a5ed x2J dH 29U 860Z 9l, AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
0�0
14 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owners Name
Information Is required for every Osterville MA 02655 5- 14-18
page. CityfrDwn 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 GOMM is less than 6"below invert or available volume is Tess
than 'Y day flow Op r 1
15ins,doc-rev.6116 Title 5 Official Inspection Form:Subaurface Sewage Disposal System-Page 4 or 17
b a5ed xeJ dH ZSU 81•0Z 96 XeW
c Commonwealth of Massachusetts
6;
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 5-14-18
per. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below 9
high round 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 cerMed
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than S 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 16,000 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 20D 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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 16.304. The system owner should contact the appropriate
regional office of the Department.
l5ins.doc•rev.6116 Thle 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 17
5 a5ed xeJ dH ZgU 81,0Z 96 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
• Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is rec wired for every Osterville 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 N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been.determined based on:
® ❑ Existing information. For example, a plan at the Board of Health,
Determined in the field (if any of the failure criteria related to Part C is at issue
❑ ® approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of,bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins.doc•ray.6,116 Title 5 Omclal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
9 abed xed dH 25:£Z 860Z 96 XeW
Commonwealth of Massachusetts
Title 5 official Inspection Form
N14 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
v��' 727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Neme
information is required for every Osterville MA 02655 5- 14-18
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 Gal. tank,2 pits.
Number of current residents: Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/lndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sci t., 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:
t5irs.doc-rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
abed xed dH £SU 860Z 96 AeW
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w
ti
727 Main Street (BLDG B
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.)
Last date of occupancyluse: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
' ❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6116 Title 5 OP 4 Inspection Form:Subaurfw*Sewege D'isposal System•Paige 6 or 17
9 a6ed xed dH £5£Z 860Z 91. AeW
Cornrnonwealth of Massachusetts
Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street (BLDG B
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 (cunt.)
Approximate age of all components, date installed (if known) and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.6'
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: 2'feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Isi age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:' 1500 Gallons
Sludge depth: 2"
t5ins.doc•rev.6116 Title 5 Official trispection Form:Subsurface Sewage Disposal System•Page 9 of 17
6 a6ed xeJ dH £9U 860Z 96 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street (BLDG B
L 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.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle 12
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Plan -Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level with/inlet Baffle outlet tee a steel cover 6"below grade. No sign of leakage or
over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of,last pumping: Date
15ins.doc-rev.6115 lido 5 offi del Inspectlon Form:Subsurface Sewage Disposal System•Page 10 of 17
0l, abed xed dH EgU 860Z 96 AeW
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
formation is
squired for every Osterville MA 02655 5- 14-18
page. cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons Per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required).is copy attached? ❑ Yes ❑ No
t5ft.doc•rev,fif S Title 5 0lficial Inspeciion Form:srbsurrace sevm2e Disposal System•Page t i of 17
abed xe� dH t,9U 860Z 96 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main Street (BLDG B
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.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No D Box
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.):
I
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
•
*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:
I
151ne.doc•rev.SM6 Title 5 Dffidal Inspection,Form:Subsurface Se*age Disposal System•Page 12 of 17
Z6 a5ed xed dH tr5:£Z 860Z 96 AeW
Commonwealth of Massachusetts
Title 5 official Inspection Form
:1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street (BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 5-14-18 required for every '
page. Cdyf town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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 2 pits in line. First pit has outlet tee, First pit has 1"water w/stain line at outlet tee. Pit
#2 Dry, Both pits have steel cover's at grade.
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
l5inadoe•rev.WS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 or 17
£6 a6ed xed dH b9:EE 860Z 91• AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form• Not for Voluntary Assessments
727 Main Street (BLDG B
.� Property Address
Wianno Knolls Condominiums
Owner owners Name
information is required for every Osteryiile MA 02655 5- 14-16
Ci JTown State Zip Code Date of Inspection
Pam•
b P P
D. System Information (cost.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6h 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
b6 a5ed xeJ dH 99:£E 860E 96 42W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�o
727 Main Street BLDG B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
Information is required for every Osterville MA 02655 5- 14-16
page. Cdy/Tcwn State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
drawing attached separately
I
t5ins.doc-rev.0116 T tle 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 150f 17
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@5ed XeJ dH 99:EE 960Z 96 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
727 Main Street (BLDG B
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.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
No 12,+
Estimated depth tofiigh ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
1981
If checked,date of design plan reviewed:
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per Design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins.doc•rev.6116 Title 5Oflicial Mpection Form:Subsurface Sewage Disposal System•Page 16 o117
LI, abed xed dH 99:EZ 860Z 96 AeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
727 Main Street (BLDG B
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
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
151ns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage oisposol System-Page 17 of 17
g� a5ed xed did 95:£Z 8I.02 96 XeW
Commonwealth of Massachusetts p 3roo S
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a - 1 ��
'< 727 Main St.Bld . B \
Property Address n J
Wianno Knolls Condominiums
Owner Owners 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:f A.When A General Information
fillingng out forms tA— l auquonnpnjz
on the computer, U ` �H OFuse only the 'S'S
key to move your 1. Inspector: a`oa��
cursor-do not DAMES •'•N
use the return James D. Sears _�: i m=
Name of Inspector :c�: ;
key. y
Capewide Enterprises,LLC r"� T�o:
"ICI Company Name � �F•51NSP��'�������
153 Commercial Street ��ip„r,tttlrtrtm��°��
Company Address
n� Mashpee Ma 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system:
® Passes n ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-15-15
nspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future unde
the same or different conditions of use.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
, 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 727 Main St.Bldg. B
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
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 1500 Gal.Tank and 2 pits.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of.
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-11/10 Title 5 Official Inspection 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
727 Main St.Bldg. B
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
B. Certification (cont.)
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 4-15-15
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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 iQ Jess than 6"below invert or available volume is less
than %day flow?ON> _ _40o-7—
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,..'< 727 Main St.Bldg. B
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.)
Yes No
❑ ® Required.pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS', cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ - the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M °�< 727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
t
® ❑ Has the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
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 727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owners Name
information is required for every Osterville MA 02655 4-15-15
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 gal precast tank,2 pits.
Number of current residents: unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundrys inspected?y stemEl Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes, ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y�. 727 Main St.Bldg. B
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 ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, IN1 , 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
tmaintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M y•y 727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 4-15-15
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.6
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: 2'
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:
1500 gallons
Sludge depth:
1"
t5ins-11/10 Title 5 Official Inspection Forth: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
727 Main St.Bldg. B
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.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle na
Scum thickness 211
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 Baffle steel cover 6"below grade. No sign of leakage or over loading.
F
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
requir required
is Osterville MA 02655 4-15-15
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No D Box
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.):
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:
I
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is required for every Osterville MA 02655 4-15-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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 2 pits in Iine.First pit has outlet tee,First pit water level at tee. 2nd pit 20"water no high
stain line. Both pits have steel covers at grade.
•
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
layer
Depth of solids la
p Y
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Tide 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
t 727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 4-15-15
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 727 Main St.Bldg. B
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.)
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Map Page 1 of 2
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St.Bldg. B
Property Address
Wianno Knolls Condominiums
Owner Owner's Name
information is Osterville MA 02655 4-15-15
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells po
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1981
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
❑ 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
r �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
727 Main St.Bldg. B
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
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
P
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ay
COMMONWEALTH OF MASSACHUSETTS
qZ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
c DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
e
yM Sye
350 MAIN STREET
WEST YARMOUTH, MA
508-775-2800
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 141 PAR 013
PROPERTY ADDRESS: 727 MAIN STREET, OSTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: JULY 20, 2006 WIANNO KNOLL CONDO
NAME OF INSPECTOR : JAMES D. SEARS BUILDING B
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: 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. l
NOTES AND COMMENTS: BLDG. B-NOTE: SYSTEM ON RIGHT ALSO PICKS UP BLDG-A, G
BLDG B ALSO HAS A SYSTEM TO LEFT. . -,
�I
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.
Cat
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING B
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: NIA
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING B
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
revised 9/2/98 3
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING B
Date of Inspection: JULY 20,2006
D]SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
X Liquid depth in pitsl is less than 6"below invert or available volume is less than%day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
N/A Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
N/A Any portion of a cesspool or privy is within a Zone I of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You,must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply .
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING B
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.
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 B
Date of Inspection: JULY 20, 2006
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 660 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 6 Number of bedrooms(actual): 6
Total DESIGN flow N/A
Number of current residents: N/A
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): YES
Seasonal use(yes or no) NO
Water meter readings,if available(last two(2)year usage(gpd): N/A
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COM MERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NOTE:MAINTENANCE PUMP AFTER INSPECTION.
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
X Shared system(yes or no)(if yes,attach previous inspection records,if any) .
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
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING B
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: RIGHT SEPTIC TANK 30"
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 PRE CAST
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: t"
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 TAPE AND
PLAN
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET TEE,2'STEEL COVER AT GRADE ON INLET END.
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.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING E
Date of Inspection: 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: LEFT SEPTIC TANK 22"
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: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: V
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 TAPE AND
PLAN
Comments:
(recommendation for pumping,condition of inlet and outlet tees of baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET BAFFLE,2'STEEL COVER AT GRADE ON INLET END.
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.)
lie
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO-BUILDING B
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 FOR RIGHT TANK 24 X 21"-30"BELOW GRADE ONE LINE IN—TWO LINES OUT.
2'STEEL COVER AT GRADE.
NOTEV-BOX FOR LEFT SIDE SYSTEM.
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, OSTERVILLE
Owner: WIANNO KNOLL CONDO—BUILDING B
Date of Inspection: JULY 20, 2006
SOIL ABSORPTION SYSTEM (SAS): X- RIGHT&LEFT SYSTEM
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 4
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
PITS FOR RIGHT SYSTEM ONE PIT 20"WATER 10'DEEP.PIT 2 5'DEEP 20"WATER,BOTH COVERS 2'STEEL AT GRADE
PITS FOR LEFT SYSTEM-PIT(1) 8'DEEP 3'WATER PIT(2)6'DEEP DRY.
NOTE:PIT(1)ON RIGHT SYSTEM BLOCK OTHER THREE PITS PRECAST ALL COVERS 2'STEEL 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 B
Date of Inspection: JULY 20, 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
SEE ATTACHED PLAN.
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 B
Date of Inspection: JULY 20, 2006
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to no groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE: PLAN ON FILE AT BOARD OF HEALTH, 12' NO GROUND WATER—SITE HIGH.
7. N G RA-1 I
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Title 5 Inspection Form 6/1 5 '_000 1 1
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COMMONWEALTH OF 1VIASSACHUSETTS TOWN OF TH DEPT.
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a 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 B
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 Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported,
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP .
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: a -3
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
SYSTEM ON RIGHT ALSO PICKS UP BUILDING A.BUILDING B ALSO HAS A SYSTEM TO
THE LEFT.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
r
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 B
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 CM R 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the- for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
f
Page 3 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 B
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 determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
i
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 727 MAIN STREET-BUILDING B
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 l 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 fonn.)
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 detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply `
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
l�
I
Page 5 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 727 MAIN STREET-BUILDING B
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 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 nonnal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
✓ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing information. 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 CM 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
1
I
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 727 MAIN STREET-BUILDING B
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: JUNE 25,2003
FLOW CONDITIONS
RESIDENTIAL-CONDOMINIUMS
Number of Bedrooms(design): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 660
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 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
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) I
Property Address: 727 MAIN STREET-BUILDING B
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.):
RIGHT SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 30"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 2,000 GALLON PRE CAST
Sludge depth: 3"
Distance from top of sludge to the bottom of outlet tee or baffle: N/A
Scum thickness: l"
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 determined: 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.2' STEEL COVER AT GRADE ON INLET END.
LEFT SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 22"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirned by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST.
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: N/A
Scum thickness: 1"
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 determined: 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 BAFFLE.2' STEEL COVER AT GRADE ON INLET END.
Title 5 Inspection Form 6/15/2000 7
i
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions: I
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING B
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)
Alann level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alann 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 FOR RIGHT TANK 24"x21",3.0"BELOW GRADE.ONE LINE 1N,TWO LINES OUT.2'
STEEL COVER AT GRADE. NO DISTRIBUTION BOX FOR LEFT SIDE.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING B
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: 2 PER EACH SIDE
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.)
PITS FOR RIGHT SYSTEM: PIT(1) 3'WATER, 10' DEEP.PIT(2)5' DEEP. DRY,BOTH COVERS 2' STEEL
AT GRADE. PITS FOR LEFT SYSTEM: PIT(1)8' DEEP,3' WATER.PIT(2)6' DEEP,DRY.PIT(1)ON RIGHT
SYSTEM IS BLOCK.OTHER THREE PITS ARE PRE CAST.ALL COVERS T STEEL 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 Form 6/15/2000 9
I
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET-BUILDING B
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 1 1 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
l
Property Address: 727 MAIN STREET-BUILDING B
OSTERVILLE,MA 02655
Owner: WIANNO KNOLL CONDOMINIUMS
Date of Inspection: DUNE 25,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater over 12 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
Accessed USGS•database-explain:
You must describe how you established the high ground water elevation:
TEST HOLE ON PLAN.NO WATER AT 12'.
Title 5 Inspection Form 6/15/2000 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t I
PART A
CERTIFICATION
MAP 141 PAR 013 OOA OOB
PROPERTY ADDRESS: 727 MAIN STREET, BLDG B, OSTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: JUNE 1, 1999
NAME OF INSPECTOR : WIANNO KNOLL CONDOS
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.lhal I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and cormplete as of the lime 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:
YES PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY 1IIF LOCAL APPROVING AUTHORITY
FAILS / '/ p
INSPECTORS SIGNATURE: _ —_ _--_- - DATE: -- (o �` _F
The system Inspector shall submit a copy of INS inspection report to tie Approving Aulhorily(Board of I-teal(h 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 aulhority.
NOTES AND COMMENTS:
NOTE: SYSTEM ON RIGHT ALSO PICKS UP BLDG A
BLDG B ALSO HAS A SYSTEM TO LEFT
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDII ION OF SYSrEM AT TI IF TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON I HE LIFE OF THE SYSTEM.
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
INSPECTION SUMMARY: Check A, 8, C, orD:
A] SYSTEM PASSES: YES
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised `9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NIA
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 srirface water supply.
The system has a septic tank and soil absorption systern and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance ____(approximation not valid).
3) OTHER
revised 9/2/98 3
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
D] SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than Y,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, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X. The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of.sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex. Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)[15.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with informa!ion on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 660 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 6 Number of bedrooms(actual): 6
Total DESIGN flow
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 15.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no) _
Non-sanitary waste discharged to the Title 5 system:(yes or no) _
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: NIA
System pumped as part of inspection:(yes or no)
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
X Shared system(yes or no)(if yes,attach previous inspection records,if any)
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
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
RIGHT
SEPTIC TANK:
(Locate on site plan)
Depth below grade: 30"
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 PRE CAST
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: 11'
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.)
BOTH TANKS AT WORKING LEVEL,RIGHT TANK INLET TEE
LEFT TANK INLET BAFFLE
BOTH TANKS HAVE 2'STEEL COVER AT GRADE ON INLET END
GREASE TRAP: NIA
(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, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
LEFT
SEPTIC TANK:
(Locate on site plan)
Depth below grade: 22"
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: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: V
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.)
NOTE RIGHT SEPTIC TANK PREVIOUS PAGE
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 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: YES
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
DISTRIBUTION BOX FOR RIGHT TANK 24"X21"30"BELOW GRADE
ONE LINE IN,TWO LINES OUT
2'STEEL COVER AT GRADE
PUMPCHAMBER: 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.)
f
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address. 727 MAIN STREET, BLDG B, OSTERVILI_E
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
RIGHT SYSTEM LEFT SYSTEM
SOIL ABSORPTION SYSTEM (SAS): SAS
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 2 2
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.)
PITS FOR RIGHT SYSTEM ONE PIT 3'WATER 10'DEEP,PIT 2 5'DEEP DRY
BOTH COVERS 2'STEEL AT GRADE _
PITS FOR LEFT SYSTEM ONE 8'DEEP S WATER. PIT 2&DEEP DRY _
NOTE PIT 1 ON RIGHT SYSTEM BLOCKS OTHER 3, PITS PRECAST
ALL COVERS 2' STEEL 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 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
SEE ATTACH PLAN
revised 9/2/98 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 727 MAIN STREET, BLDG B, OSTERVILLE
Owner: WIANNO KNOLL CONDOS
Date of Inspection: JUNE 1, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate __ _ Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater OVER 12 FEET
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
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 12
F�P,77-
FEx 3.4..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
6
................OF...-. .............
Apphration for Uhiposal Works Tonstrurtion Frrmit
Application is hereby made for a Permit to Construct (0<) or Repair an Individual Sewage Disposal
System at: &I-
..................... ...................... I.. ...:�......q.........................
.......................... ..,��A/:�
Location,A4d,,,ss 7 or IE.��
............ .................... .....
I
....................... ............ ....... ... ................. .......
Installer Address
-Type of Building Size Lot_..e.-,! -Z-e-V
- ...Sq. feet
_ -------
Dwelling—No. of Bedrooms.._.........................................Expansion Attic Garbage Grinder Wt�
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ............................................................................................................. ....
Design Flow............ ....................gallons per person per clay. Total daily Row..................... ...0.............gallor)d.
WSeptic Tank—Liquid capacity4? allons Length...... ..... Width._5...... Diameter---------------- Depth....-.4..........
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....._ sq. f t.
Seepage Pit No_____ ___________ Diameter... Depth below in1et.A5_:::V..... Total leaching area... q. f t.
Z Other Distribution box (X) Dosing t* ( )
?
Percolation Test Results Performed by... . ............. .......... ..../ Y Date....._...................-5o— nr..............
Test Pit No�......kZ.--minutes per inch Depth of Test Pit-----Z-2 ...... Depth to ground water---/Q
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.._..........._.._.. Depth to ground water.-_.._..._...._......_..
0 ----------------------- ------------ ................ ......;;...........f--------------------------------
Description of Soil.......... Z ..............................----
(xj
----------*----------- ............
........................................ ....... . ..�a - a_
----------*------------*------------ ...... ......e......................................................
.......................... ..... ..................................................................................................................I....................................................
Q Nature of epa I or Alterations�Answer when applicable....7�;�_ -------6-5-Y
.................. .... ... .... .................................................................................................................................................................
gne agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
v f YLS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
SO a Certificate of Compliance has been issued by the board of health
3 Signed.---- ........ ......................... ..—2 ..........
_2.�Aj
Approved By.......... /Da.te..............
• Date
tion Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo........................................................ Issued.......................................................
Date
'r
M
No.....11... ::........ FEB...;3.o...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. GtJ/✓.............OF....464ze... 1O..: 1iW _ ..it.........
ApplirFation for Digpvii al Works Tongtrnrtion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
43
..
Location- ss or Lot
.....---..._� t_�''.y?. _G .. c�.s...PL........................ . ... 1 .. ......
✓ Installer Address
d Type of Building =: Size Lot'..........1�..G::......Sq. feet
U Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) ,< Gar' age Grinder Wo
aOther—Type of Building ............................ No. of persons............................ Showers ( n) — Cafeteria ( )
dOther fixtures ..............................................................
W Design Flow............ 157.................;gallons per person per clay. Total daily,9ow...............9S.0.............galloq.
WSeptic Tank—Liquid capacityallons Length.....,,_..... Width.._5...... Diameter................ Depth.....6.......
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........3........... Diameter...!` -. .. Depth below inlet._:=.jQ..... Total leaching area..2�.S..sq. ft.
Z Other Distribution box (X) Dosing to k ( )
, _ n
aPercolation Test Results, Performed by.._.�' �._ '.r ?l-.'. 11! < :_..�-..... Date......-cj...... ...... �
.a Test Pit No ...... ..._..minutes per inch Depth of Test Pit-__-_l 2__. .. Depth to ground water../t/�^-
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O l ,_ �. ... .....................
Description of Soil � ' c3 .. '.r' s��..... ------ -�"-fit i - f. =}
V -� s
W ................................!-_---•------------__---_-__-__-----_-__-_-_._---.----.-.---------____--_--_--_ __----___-----_.
U Nature of fiRepa s or Alterations—Answer when applicable_.._... _..s.--_ ,� _. ..s rs f
� , = ^--•--•-------•-------•------------------------------•-------------------•---------------------•------------------•------•-------••---- l..
nie�rsignT agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the pro _ Hof L.LT1_p. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
'rat' n a Certificate of Compliance has been issued by the board of health.,
c., So THW C _j /
g 3 Signed..•.... �� --•-•-.......-••---•. - °/-3�..----••.
Date
<?
f s-� t :�
on Disapproved for the _1_11wing,re6Ions— = ��Z-••--•-----------------------•--------•---------------•--•----.-
J _ o Date
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................._..................;***'*.............*......... .......
-aArrtifirttrrlaf'TvrMt'j-Tlftanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-----•----
by -----------------------•---------/--•-•-•--••-------•--Installer------•----------•-----------------•--------------� .....------••-•---------•----......-----
........................
has been ir3stalle in accordance with the provisions of:m3mL 5,-of Thee State Sanitary Code as described in the
application-for Disposal Works Construc m fion Permit No........... =--'.................... dated.._..........-------------•------------.......
THE ISSUANCE OF THIS CERTIFICATE SHA`L'_N �ONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•-•--......•---•----•----....---•------------•-•----..........-- Inspector................-...................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........O F _2 l..
No._ .. r,.� i` d ".ti � <- -G•rr� FEE...-
�i��n�ttl larks ��an��nr�inn r�nti�
Permission is hereby granted. --------- ...............................
to Construct (L,-)'or Repair ( ) an Fd victual Sewer g"Disposal System
at No.---------_ ...—^..._..__._c_. _.,- i-7 =-----
r ss'i'I�� J------•-------c f y_� Street�L 5-._ Cr...
as shown on the application for Disposal Works Construction Permit No.____-•-------------- Dated... ..........
DATE.._? Y- .............................................. Boar; Heal h
FORM 1255 HOBBS & WARREN. INC., PUBLISH S