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HomeMy WebLinkAbout0920 MAIN STREET (OST.) - Health (3) a 920 Big 3 M MainStreet (Ost.) . -Osterville P s �. A = 117 056 m } FQ Y i O F y o i �Commonwealth of Massachusetts � ova �n Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) u Property Address Osterville Village Condos (First Property Mgmt.) .,, Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. OF t z fd Important:When filling out forms A. Inspector Information J �� tP 0=� •q�'yG on the computer, JAM ES N use only the tab. James D.Sears =�: key to move your Name of Inspector cursor-do not Ca ewide Enterprises *- use the return - p p Company Name key. 153 Commercial Street �/i �5t1 NSPtE;'��``��\` rab Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1-22-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) u Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 2000 Gal. Tank D Box and pit. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ tN ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Rio Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form = FIo Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments u 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cool is less than 6" below invert or available volume is less than '/2 day.flow 00/7 ❑ ® 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. ❑ ® 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts ,p Title 5 Official Inspection Form _ lle Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg #3 Front System) 9 ( u Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form iii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 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 x#of bedrooms): 440 Description: 2000 Gal. Tank , D Box and pit. Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t; 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Yearly Pumping 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 Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 20" 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" PVC SCH 40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts :. Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 1" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal. Precast H-20 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 2„ Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" - How were dimensions determined? Asbuilt-Tape-Past ReportSludge 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.): Yearly Pumping. Tank at 10" below grade w/both covers steel at grade in black top. In and outlet tee's. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form .0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Camera D Box from tank. D Box under black top. No sign of over loading or solid carry over. Box looks to be solid. F t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form = .I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is 'required for every Osterville MA 02655 1-18-19 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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osteryille MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one precast pit per asbuilt. Pit under black top parking. No sign in D Box of over loading from pit. Camera out to 6"water in pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form lie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 YltLr40--£ CoN,�os oRT Q - 41 7Ec(l 0 r C% ��A c% Is C c Commonwealth of Massachusetts s. Title 5 Official Inspection Form File Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope '� ❑ Surface water ❑ Check cellar . ❑ Shallow wells /Vo 30+, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1981 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W.off past report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =u— 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos (First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 ( Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 DD/{ c Commonwealth of Massachusetts �n ,q Title 5 Official Inspection Form <ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; ,•u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville ✓ MA 02655 1-18-19 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. ��ppullu/uU,,, �A OF Important:When A. Inspector Information 614 l3b66 filling out forms o: G on the computer, i g: JAMES James D.Sears =rV �+" use only the tab J�L�C^ = key to move your Name of Inspector cursor-do not %* use'the return Capewide Enterprises .. •cF V o Company Name key. 153 Commercial Street °°�;��5,,NSpEG`����` r� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true,.accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1-22-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I i Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 D Box and pit. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 118 Commonwealth of Massachusetts Title 5 Official Inspection Form _ la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 II c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in Ga&&peel is less than 6" below invert or available volume is less than '/2 day flow Ph` ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is I required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ® a Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form .I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 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 x#of bedrooms): 440 Description: 1500 Gal. Tank D Box and leaching pit. Number of current resident Unknown s Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Yearly Pumping 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 I'� I c Commonwealth of Massachusetts Title 5 Official Inspection Form lie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18" 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" PVC SCH 40. t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3 Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): ' Depth below grade: 1 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 Gal. Precast H-20 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 1" 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? Asbuilt-Tape-Past Report 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.): Yearly Pumping. Tank at 1" below grade w/inlet cover steel 6" below grade. In and outlet tee's. No sign of leakage or over loading. Outlet cover under black top. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �R Title 5 Official Inspection Form `Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �v 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19, page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Camera D Box from pit. Box at 3' below grade under black top. One line out. No sign of over loading or solid carry over. Box looks solid. I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form F1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Fio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is Osterville MA 02655 1-18-19 required for every page. City/Town State Zip Code Date.of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one precast pit. Pit at 4' below grade w/steel cover at grade. Wet bottom w/stain line at 28" above water line. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form �' to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of sours 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 �I c Commonwealth of Massachusetts �� .• Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .,, 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters, the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Jan 1419,12;55p Capewide Enterprises 508-477-4977 p.6 Map. Page 1 of 2 Town of Barnstable Geographic Information System Patter T6wer I 6xbm Map Abt tra Map Size .i Zoom Out l III III On 11t 1C} AIM 'Ai1 1 Y t 5 L Y 0 0 Fe t Set Scale 1"= 20 ' ( Aerial Photos MAP DISCLAIMER /`�.roriwhl 7MAr�f11i1 T—m A A—f.IJ. IAA All A A f. ..e.w . .. .,.�new n......, r � . .. +n ••..rn«i+n. n ...�...� �in..,nn.n ZJo I*ova &K I • Commonwealth of Massachusetts Title 5 Official Inspection Form f I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 u 920 Main Street#3 (Rear System) Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells j 0 Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,-date of design plan reviewed: 1981 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As- Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: G.W. off past report 30+'. Bottom of pit at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street#3.(Rear System) �V Property Address Osterville Village Condos (First Propert Mgmt.) Owner Owner's Name requinform r on is Osterville MA 02655 1-18-19 requiredd for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 Failure Criteria and 6 Checklist completed ( ) (Checklist) p ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 117 -0'5�-l 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •, m 920 Main Street Bldg #3 ( Front System) Qr� Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Cisterville V/ MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection W Inspection results must be submitted on this form. Inspection forms may not be altered in a1 way. Please see completeness checklist at the end of the form. Important:When filling A. General Information on forms the computer, �,�H OFfAf use only the tab 1. Inspector: �`�� � key to move your cursor-do not ,lames D.Sears JAMES cp use the return m key. Name of Inspector c>: Capewide Enterprises, LLCCompany Name Si IM IC �j 153 Commercial Street �N Company Address RM W Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-18-16 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing.this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under. the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 2000 Gal Tank D Box and pit. 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•3/13 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 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed Ej Y F1, 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 920 Main Street Bldg#3 ( Front System). Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in aamqmwisl is less than 6" below invert or available volume is less than '/z day flow P>i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 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 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Citylrown 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 r 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•3/13 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 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 2000 Gal. Tank,D Box and pit. 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Sv0yv0v 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool Elp ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20" 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" PVC SCH 40. Septic Tank(locate on site plan): 1" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal.Precast H-20 Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape-Past ReportSludge 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.): Yearly Pumping. Tank at 10" below grade w/both covers steel at grade in black top. In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments §20 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Camera D Box from tank. D Box under black top. No sign of over loading or solid carry over. Box looks to be solid. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leachiing is one precast pit per asbuilt. Pit under black top parking. No sign in D Box of over loading from pit. Camera out to pit 6"water in pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Vlewar Custom Map Abutters Map Sire Zoom Out l 11n Y ��• f 1 '+ 1 l: 1 r' 20 Fee Set SCOIei 1" = 20 , AerIal Photos MAP oJOCWMER IY,muInM'IMr-9Mfl TMs,n1 Re'"01011A 1J0 All An*a, Ob— T ,�nn��nn. n ,inn Mn�n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg #3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells N Estimated depth for gh ground water: 30+ 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: G.W.off past report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Front System) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I Commonwealth of Massachusetts i Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville_Villa_ge Condos.(First Property Mgmt.) Owner Owner's Name required for every / information is ostervill- V MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection o Inspection results must be submitted on this form. Inspection forms may not be alteredin any way. Please see completeness checklist at the end of the form. Important:When filling rms A. General Information �� ��3 on out the computer, N OF use only the tab 1. Inspector: �:0 key to move your Oa= yG cursor-do not James D.Sears JAMES N use the return — m key. Name of Inspector =_c�: ;0 Capewide Enterprises, LLC �11 Company Name ''% •`c 153 Commercial Street INSPX\\``�� Company Address EG Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority oal� 1-18-16 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal Tank D Box and pit. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System,Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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 usEpsO is less than 6" below invert or available volume is less than '/2 day flow #0o t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 II Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E] ® 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•3/13 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 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and leaching pit. Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system? Include laundry system inspection P 9 Y ( ry Y p El Yes ® No information in this report.) Laundry system inspected? ❑ 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: PresentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Vifll_age Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osteryille MA 02655 1-18-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18" 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" PVC SCH 40. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I! If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal.Precast H-20 OilSludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0" Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? Asbuilt-Tape-Past ReportSludge 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.): Yearly Pumping. Tank at 1" below grade w/inlet cover steel 6" below grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 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 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osteryille MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present:. ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Camera D Box from pit. Box at 3' below grade under black top. One line out. No sign of over loading or solid carry over. Box looks solid. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is Osterville MA 02655 1-18-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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(mote condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one precast pit. Pit at 4' below grade w/steel cover at grade. 1'water w/stain line at 28" above water line. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w W 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 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-3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 "Jan. 13. 2016 12:02PM No, 0320 P. 12 Page I of 2 Map. Town of Barnstable Geographic information System er Cuorn Abutters Map Size ■ Zoom Out I I I I I I 1 1 11n Parcel View Map r o 'o e t Set Scale 1" = 20 Aerial Photos I MAP DISCLAIMER r•Mull 9Mr.AMn Tr+r.iA rJ;%q-6)&kI6 (la all AAM4#4~111 r . •rrr nnA ,fir nw�, • 1 r` .• - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM s 920 Main Street Bldg #3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is required for every Osterville MA 02655 1-18-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells No Estimated depth to high ground water: 30' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1981 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As- Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W.off past report 30+'. Bottom of pit at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 920 Main Street Bldg#3 ( Rear System ) Property Address Osterville Village Condos.(First Property Mgmt.) Owner Owner's Name information is Osterville MA 02655 1-18-16 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3( Front System) Property Address Osterville Village Condos. First Property Mgmt.,- Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 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 ng out forms A. General Information , ��puunuuf on l the computer, ```� ,1H OF Mgss�,,���i use only the tabs 1. Inspector: - `moo`' ••9CyG�' key to move your 3�: N cursor-do not . - rr,^, JA M ES m James D. Sears l!/�(�_ =o: use the return - _� SFARS ke Name of Inspector *; Y• Capewide Enterprises,LLC y--�I Company Name ���4 5 1 N SPE���` 153 Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number ' B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: 0 .Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority d 1-8-13 spector's Signature - - Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the 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•11/10 Title 5 Official ins cti n Form:Subsurface Sewage Disposal System•Page 1 of 17 • - �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments• ; M '�t 920 Main St. Bldg#3 ( Front System) Property Address O_sterville Village Condos. First Property Mgmt. Owner Owner's Name information is Osterville MA 02655 1-8-13 required for every ' page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) R 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 ezist.,Any failure criteria not evaluated are' indicated below. Comments: , B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement,*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 920 Main St. Bldg#3(front System) t Property Address Osterville Village Condos. First Property M mt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 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): 3 ❑ 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 ora salt marsh t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage'Disposal System-Page 3 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments "( 920 Main St. Bldg#3 ( Front System) Property Address Osterville Village Condos. First Property M mt. Owner Owner's Name information is , required for every Osterville MA b 02655 1-8-13- page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water y suppl , ❑ , 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. t 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes".or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an.overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6° below inverfor available volume is less than %day flow t5ins-11116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspectibn Form Subsurface Sewage Pisposal System Form-Not for Voluntary Assessments yt 920 Main St. Bldg#3( Front System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA =02655 1-8-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.)- Yes No Required pumping more than 4 times in'the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. f '❑ ® 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. r ❑ ® 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 6 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 wi.th 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 El ❑ the system is within 200 feet of tributary to a surface drinking water supply 0 ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, . or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts b Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3( Front System) Property Address Osterville Village Condos. First Property M mt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 page. City/Town State : Zip Code -Date of Inspection C. Checklist Check if the following have been done:You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built"plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ ' Was the facility or dwelling inspected for signs of sewage back up? T . ® ❑ 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): -- Number of bedrooms(actual): 4 f 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 : s Commonwealth of Massachusetts W Title 5 'Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3( Front'System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is sterville MA 02655 1-8-13 required for every O ' page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 2000 gallon tank; D Box and,leaching pit Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes E No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system'inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No t Water meter readings, if available last 2 ears usage d NA g ( Y 9 (9p ))� Detail: • Sump pump? ❑ Yes ® No Last date of occupancy: Present Date - Commercial/Industrial Flow Conditions: Type of Establishment: d Design flow(based on 310 CMR 15.203): Gallons per day Y(9Pd) Basis of design flow(seats/persons/sq.ft., etc.)- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form`, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 920 Main St. Bldg#3 ( Front System) Property Address , Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 page. Cityfrown 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,pait of the inspection? ❑ Yes ® No ' If yes, volume pumped: gallons How was quantity pumped determined?` Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared.system (yes or no) (if.yes, attach previous inspection records, if any) ❑ Innovative%Alternative technology' Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank.-Attach a copy of the DEP approval., ❑ Other(describe): t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main St. Bldg#3( Front System) Property Address r , Osterville Village Condos. First Property Mgmt. Owner owner's Name information is required for every Osterville MA . 02655 1-8-13 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): 20„ Depth below grade: feet Material of construction: r ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition ofJoints, venting, evidence of leakage, etc.): Pipeing is 4" pvc sch 40 Septic Tank(locate on site plan): Depth below,grade.- feet Material of construction: � . ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal,,list age: years. Is age confirri ed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 2000 gallon precast Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 920 Main St. Bldg#3( Front System). Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is Osterville MA 02655 1-8-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of,sludge to bottom of outlet tee or baffle 29" Scum thickness 1 Distance from top of scum to top of outlet'tee or baffle Distance from bottom of scum to'bottoi'n of outlet tee or baffle 17' How were dimensions determined? Astiuilt-.TapePast report 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.): Yearly Pumping. Tank at.10"below grade w/both covers steel at grade in blacktop, in and outlet tee's, No sign of leakage or overloading. Grease Trap,(locate on site plan): Depth below grade: feet Material of construction: •. ❑ concrete ❑'metal ❑fiberglass ❑ polyethylene ;-❑other(explain): Dimensions: M' 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 Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth .&Massachusetts a W Title, 5 Official Inspection Form �R Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments �y 920 Main St. Bldg#3( Front System) - Property Address Osterville Village Condos.: First Property Mgmt. Owner Owner's Name information is required for every Osterville MAr 02655 1-8-13 page. + City/Town State r• 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)-%, , i Tight or Holding Tank(tank must be.pumped at time of inspection)(locate on site plan): Depth abelow grade: Material of construction: ❑ concrete 0 metal ❑fiberglass El polyethylene other(explain): Dimensions: Capacity: gallons Design.Flow: . > gallons per day%, R, Alarm present: El Yes ` ❑' No Alarm level: ;Alarm in working order:; ., .E] Yes El, No Date of last pumping; Date Comments(condition of alarm and float switches, etc.);:, Attach,copy of current pumping contract(required). Is copy attached? El Yes �, No t5ins-11110 Title 5 Officiallnspedion Form:Subsurface Sewage Disposal System-Page 14 of.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3 ( Front System) f Property Address ° Osterville Village Condos. First Property gmt. Owner Owner's Name e information is required for every Osterville y' MA. -02655, :_ 1-8-13 ` page. City/Town State, Zip Code Date of Inspection' D. System Information (cont' r : Distribution Box(if present must be'opened) (locate on site plan): .ou - - Depth of liquid level above outlet invert Comments(note if box is level and distribution to outletsequal„any evidence of solids carryover, any evidence of leakage into or out of box, etc}. `.,. ` Camera D Box from tank, D Box under-black top, No sign of over loading.or solid carry over box . looks to,be solid. Pump Chamber(locate on site plan): Pumps in working order: El Yes El No Alarms in working order: ❑ Yes ' E No Comments note condition of um chamber, condition of pumps and appurtenances,-( P p P I? PP ) '� J Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why; ; t5ins-11/10 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main St. Bldg#3 ( Front System) Property Address , Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA . 02655 17$-13 page. Cityfrown F state Zip Code - Date of Inspection D. System Information (cont.)} Type: ® leaching pits number: 1 ❑ 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 one precast pit per asbuilt. Pit under black top parking. No sign in D Box of over loading from pit. 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 El Yes ❑ No t5ins•11110 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 p f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 't 920 Main St. Bldg#3 ( Front System} Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is sterville ' MA• 02655 1-8-13 required for every O I, 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.): . R 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.): e - 4 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form p - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main St. Bldg#3 ( Front System) Property Address O_sterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 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 n F t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I ' �®IEEE® -• - - •• • i - -_ M —01 �x r..s- �� try - -. a g - f �n a'" r ® 1 � a 5 i WIM BAR RM -.c,' ..-✓r ' �'P r 1 n �' ter 3 F� ...t aYe a 1t }Tt ` 'a f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main St. Bldg#3( Front System) Property Address , .Osterville Village Condos. First'Property Mgmt. Owner Owner's Name information is Osterville MA 02655 1-8-13 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® 'Check cellar ❑ Shallow wells Estimated depth to high ground water- feet Please indicate all methods used to determine the high ground water elevation: ® . Obtained from system.design plans on record • y 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: G.W. off Past Repor 30+'t 1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` "< 920 Main St. Bldg#3 (Front System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA. 02655 . 1-8-13 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 4 t ' r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 • Commonwealth of Massachusetts k . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property M mt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when-ng out forms A. General Information on l the computer, �1§01, OF use only the tab •.9�,��� 1. Inspector: key to move your ' O: ''•yG cursor-do not James D. Sears - JA M ES N use the return key. Name of Inspector IRSy s# Capewide Enterprises,LLC �'•. o:'� , Company Name 'y�s• F •` `\�z 17 153 Commercial Street �°jFnult uS? G�`\``` Company Address Mashpee , MA 02649 City/Town aState Zip Code 508-477-8877 , S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-8-13 spector•s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a'design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report-only describes conditions at the time of inspection and under the 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. � 4 �3 e t5ins•11/10 Title 5 Official Ins p:Sub.,rface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - ti 920 Main St. Bldg#3 ( Rear System) F Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name , information is required for every Osterville MA` 02655 1-8-13 page. City/Town ° 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: 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 replacedwith 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 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. i Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 . page. Cityrrown State Zip Code Date of Inspection B. Certification (cont:) B) System.Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box:System will pass inspection if(with approval of Board of Health): ry ❑ broken pipe(s)are replaced * y ❑ Y _❑ N ❑ ND(Explain below): . Elobstruction 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 pipes)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 4 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg!#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is Osterville MA, 02655 1-8-13 required for every ' page. City/Town State Zip Code bate 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 106 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 ❑ ED 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 El ® Liquid'depth in I is less than 6" below invert or available volume is less than Y2 day flow 4 FIV C//iye' t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 b w Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments M 920 Main St. Bldg#3( Rear System) Property Address ° Osterville Village Condos. First Property Mgmt. j 4 Owner Owner's Name information is 9 required for-every Osterville MA .02655 .1-8-13 page. Citylrown State -Zip Code Date of Inspection B. Certification (cont.) •° Yes 'No ❑ ® - Required pumping more than!4 times in the last year NOT due to clogged or ,obstructed pipe(s).,Number of times pumped: ❑ _ Any portion of the'SAS, cesspool or privy is below high.grotind*water elevation. El ® Any portion of cesspool or privy,is within 100 feet of a surface water supply or tributary to-a.snrface water supply. _ ❑ ® Any portion of a cesspool`or privy is within a Zone of a public well. ❑ Z. Any portion of a cesspool or privy is within 50 feet of a private water supply well = ❑ Z Any portion of a cesspool or privy;is less than 100 feet but greater than 50 feet ' from a private water supply well with no acceptable water quality analysis. [This n 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 beattached to this form.] " ❑ The system is a cesspool serving'a facility with a design flow;of 2000gpd- Izi :101000gpd. � f ❑ ® The system fails. [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 w, 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,,inaddition 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'watersupply a y El the system is located in a nitrogen sensitive-area(Interim Wellhead Protection El 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. r .n 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 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property M mt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 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 6y'the owner, occupant, or Board of Health c ❑ ® 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 Lthe 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): ~- Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA r 02655 1-8-13 page. CityrFown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 gallon tank, D Box and leaching pit Number of current residents: unknown Does residence have a garbage grinder? 0 Yes ® No Is laundry on a separate sewage system? [if yes separate inspection.required]- ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ '.Yes ® No Water meter readings, if available last 2 ears usage p d NA . 9 ( y ,g (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): ih 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: s , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f - . Commonwealth of Massachusetts'- . Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �t 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville AMA 02655 1-8-13 ' page. Citylrown State Zip Code Date of Inspection D. System Information (cont:) Last date of occupancy/use: Date Other(describe below): E" General Information Pumping Records: Source of information: {5 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: a _ ® Septicjank, distribution box, soil absorption,system ❑ Single,cesspool El Overflow cesspool ❑ Privy El Shared system (yes or no) (if,yes; attach previous inspection records, if any)• - ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest ' inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. `. ❑ Other(describe): t5ins•11110 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r• 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner owner's Name information is required for every Osterville MA 02655 1-8'-13 page. City[Town State - Zip Code Date of Inspection D. System Information (cont.) , Approximate age of all components, date installed(if known)and source of information: 1981 Were sewage odors detected when arriving at'the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 1811feet 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"pvc sch 40 Septic Tank(locate on site plan): 'Depth below grade: f feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If,tank is metal, list age: years Is ag6confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ 'No ' Dimensions: 1500 gallon precast 1 . Sludge depth:- t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 r Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 920 Main St. Bldg#3 ( Rear System) Property Address Osterville Village Condos. First Property Mgmt.` Owner Owner's Name information is Osterville MA 02655 ' 1-8-13 required for every page. Cityrrown State Zip.Code Date of Inspection D. System Information (cont.) , Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee.or baffle V Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Asbuilt-TapePast report 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.): Yearly Pumping. Tank at 1' below grade w/inlet cover,steel 6" below grade in and outlet tee's, No sign of leakage or overloading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete E metal r E fberglass ❑ polyethylene other(explain): Dimensions: F Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: 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 , 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt.k , Owner Owner's Name ` information is Osterville MA 02655 1-8-13' required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) T 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.- 0 concrete ❑ metal ❑fiberglass 0 polyethylene ❑other(explain): Dimensions: Capacity:- " ,F. gallons f Design Flow: , gallons per day -..Alarm present: 0 Yes 0 No Alarm level: Alarm in working order', 0 Yes 0 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 0 No t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name _ information is Osterville MA 02655 1-8=13 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 0" 4 I Comments (note if box is level and distribution to outlets equal,-any evidence of solids carryover, any k evidence of leakage into or out of box, etc.): .1 - , Camera D Box from pit. Box at 3',below grade under black top, One line out. No sign of over loading or solid carry over box looks to be solid. Pump Chamber(locate on site plan): .Pumps in working order. ❑ Yes E] No Alarms in working order: 0 Yes ❑ No t Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3 ( Rear System) + Property Address b Osterville'Village Condos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 Zip Code Date of Inspection page. City town State D. System Information (cont.) Type: ® leaching pits number: 1 . ❑ leaching chambers number: } ❑ leaching galleries number: ❑ Teaching trenches o- number; length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: El innovative/alternative system 4 F Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one precast,pit. Pit at 4' below grade w/steel cover at grade. 8"water w/stain line at 28" above water line i 4 • Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration - r Depth—top of liquid to inlet invert Depth of solids layer F Depth of scum layer ` Dimensions of cesspool Materials of construction Indication of groundwater inflow. ❑ Yes ❑ No t5ins•11/10 Title 5 official Inspection porn:Subsurface Sewage Disposal System•Page 13 of 17 • Commonwealth of Massachusetts < Title 5 Official Ins ection Form p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' " 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name information is Osterville MA 02655 1-8-13 ` required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): - - a a • - + Privy(locate on site plan): _ Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation, etc.): % : t5ins•.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owners Name information is required for every Osterville MA 02655 1-8-13 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: Z hand-sketch in the area below ❑ drawing attached separately l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 15 of 17 • �-.•� ':r: —i a '� 5# — ..a t _ v. 01. y� � t 6 4 u� Commonwealth of Massachusetts uTitle 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3 ( Rear System)" Property Address Osterville VillageCondos. First Property Mgmt. Owner Owner's Name information is required for every Osterville MA 02655 1-8-13 page. CityTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ®Check Slope ® Surface water ® Checlrcellar ¢ ❑ Shallow wells Estimated depth to high ground feeett water- 3 Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record x F 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: As- Built ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water.elevation: G.W. off Past Repor 30+' Bottom of pit at 10' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-,Page 16 of 17, S { Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 920 Main St. Bldg#3( Rear System) Property Address Osterville Village Condos. First Property Mgmt. Owner Owner's Name ' information is required for every Osterville MA , 02655 y 1-8-13 page. Cityrrown State Zip Code, 'Date of Inspection E. Report Completeness Checklist Z 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 I 1 t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No...... z.sffy.. Fis.... .v............... THEBOARD ALTH�OFUA�S'SAC Tu TS ttdd `� V .....OF.............. TH ...................................... ..... .. Pill 'd v .� r�ir�a Ilan for Uigvuiiaal Works Tonstrurtinn ramit hpplication is hereb made for a Permit to Construct or Re air an Individual Sewa a Dis osal Y (� P ( ) g P System at: Ss© a /�1?��c .5 ........., � - e2. f ............................... ..............___. .. �. ... ..=� ` .... ocation-Address or Lot No. Owner ........................Address ...1` !C j� ---•---------------------- • -----.---.-•--- --•---------•---------......... ............ -------- 'Installer Address V�I-7..S feet � Type of Building Size Lot...._._.y.__..____ q. Dwelling—No. of Bedrooms..............�'�.-----_ ----_---------Expansion Attic ( ) Garbage Grinder ( ) p•, Other—Type of Building _C6.?V)20.._ No. of persons........Z............... Showers ( �Ts — Cafeteria ( ) a'' Other fixtures .___ w Design Flow................ ...........gallons per person per day. Total daily flow........ _.....,0.....................gallons. WSeptic Tank—Liquid capacity940.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—. o......:.............. Width.................... Total Length.............__ Total leaching area..._...---------.--sq. ft. Seepage Pit No...... ........ Diameter..l���.._.._. Depth below inlet__.?` ... Total leaching area'l q. ft. z Other Distribution box (1,-T Dosing tank ( ) Percolation Test Results Performed by..Ro.(�... Date... . �.lc%1...... Test Pit No. 1......— -__minutes per inch Depth of Test Pit_. _lr Depth to ground water---_----__^---_.- Lt, Test Pit No. 2................minutes per inch Depth of Test Pit....l ._.___.. Depth to ground water......... ax 7�---------------------..1 --••-•--------1 - .` •-•--�f............-•--•.......,-. ..7,.F�..4...-`-•-�••-•.._...G---p�--s.p...i.. O � © �. - © 1ptonoo . .-© � . L2es ...... ©_ - " .... .v � . . . ..� S ' . U i UNature of Repairs or Alterations—Answer when applicable................................................................................................ -----•-•••-----•-•------•--••..............•----•------•--•----••-•-•-•-••--------•-•---............--------------•-•------------•-•---•--••----••-------•-•--•-•.....-•--•-------------•---•-•--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'TI LT. . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bo =rd ealth. Signed.._. �� _.�. ....... .. . ..........i:i. �••- / �. Dattee Application Approved By........................ �.�f ----------------•- ..... -�/.--��-------- Date Application Disapproved for the following reasons:......................................................--------------------------------___.. D ----.......... --------------------•-•-----••--•-•-•-----------....-----.......---...--•--•----.......---••--•----...---•------•....---•---------•---------•----------•-------•-•--•---••----••------••--••------...-•- Date PermitNo......................................................... Issued........................................................ Date Fina........ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Uiipoottl Work.6 Toustrurtion Prrmit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage-Disposal System at: / J .. l i.� ' ..._..._ �✓ ....... ::.?.®4....i� l // �.._..Rk............. Location, Address f f or Lot No ......................... .. L.psi 2.�__.... ....... � f ............... Owner _•-••--••••-•--••••--•••------••Address W �•= .::::�:,:: � ................•-•---.._..-----•-------- ••-...._._.. -••---...- Installer Address U Type of Building �; Lot__/SizeZA .Z..Sq. feet ,•, Dwelling—No. of Bedrooms______________`��'__________________________Expansion Attic ( , ) Garbage Grinder ( ) Other—Type of Building _ lf.✓.___ No. of persons________?_________________ Showers ( — Cafeteria ( ) a' Other fixtures W Design Flow................... ..........gallons per person per day. Total daily flow........ . ._._.__.________._____gallons. 9 Septic Tank—Liquid'capacity�n(Pgallons Length................ Width................ Diameter................ Depth................ Disposal Trench—�UN)o_ ____________________ Width___._.__._._.._-__ Total Length_.____._____._ Total leaching area....................sq. ft. Seepage Pit No......__.-..._...__. Diameter.____✓_____..._. Depth below inlet...--'..:.......... Total leaching area___. sq. ft. Z Other Distribution box (L,— Dosing tank a Percolation Test Results .1 Performed by-_Z;k�-'___ j_7 f:�_____f •Test Pit No. L___ _minutes per inch Depth of Test Pit-. `ll _ Depth to ground water_____ ________________ 44 Test Pit No. 2________________minutes per inch Depth of Test Pit-----.yP�__f_.__. Depth to ground water---- ............ , Al if r' - W � re •••. -•� --- -• - " 0�Z � ZepfD Description of Soil.._ l f n � -'� ' � a CCu 1 •-•---•-----------------------------------•-------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•---------------------------------------------••---•---•-••---...............................................--------------------------------------•-----------------------._......--••••_•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board ealth. SSig �i-�-►j'' -fir . ` '' .� I ned_.fr _...�:............�C........... .....-----•-•------- F =+�` ==_.....�-•-- Date Application Approved BY == � ..�; , � ��---_--.- te Application Disapproved for the following reasons:-----•---------•-----•-•----•--•-----------------------------•----------•-------••---•-••-................... ---•--------------------•-....••---•--------•---•-----•----......•-••-••-••------•---........------•-•-•-•--•----...--•-•--•----•-•-•••---•-•-----•-•--•---------••-••-•-•-•-•------ ............. Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 4F:27e�k HEALTHY'..... r -:..........OF..... C:%:? ?1............ ................•--.................... (9rdif iratr of Toutpliatta THIS IS TO��EEFY That the Individual Sewage Disposal System constructed 06 or Repaired ( ) by ....f !....j._- . ...--•---------•---------------------------------•--------......-----....-•----._....----------------.._..----............__.._....._---------- a Installer ••• •- has been installed in accordance with the provisions of m T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. ______________ dated................................................ THE ISSUANCE OF THIS, CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.........................---•-=----•------------•-•--....-•-......_.....--_--•--- THE COMMONWEALTH OF MASSACHUSETTS ---�` BOARD,,,_OF HEALT OF.. u` :_ .. FEE....7............. Disposal Works Tonstrt ion rruti# Permission is hereby granted._. fe/ ='" =1=== r`�-! � =e y�`------------------------•---._...._...---------.........----....................._.. to Construct) or Repair ( ) an Individual Sewage DDispo sal System �c S t^ IJ f' f' VA- at No.--=�---==--�-----•-�---.z�:..._:_r_:........�.J._.t�r:'�_.57.............-`-�====�a:�"_�'.1.:�,tll�.c"_..------�•-........................................ Street as shown on the application for Disposal Works Construction Permit No_____________________ Datgd.......................................... gth � y- '�'* - ---------------••---•----___-- Board a DATE...........................................!2 .......... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS } n TOWN OF�BARNSTABLE llr,.,,���r`�% 3 A�+� o70 LOCATION q MAv\ rr �jSlOtjk OlA(t-(-WS WAGE# 'VILLAGE OSTb(v, ASSESSOR'S MAPS-, PARCEL INSTALLERS NAME&PHONE NO. _ .SEPTIC TANK CAPACITY 9-CV) LEACHING FACILITY: (type) a— l—, /S (size) MUV NO. OF BEDROOMS K OWNER _ Qfl—eryA ' A(ti• C o,, JJ O PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facx;{.If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa ility) Feet FURNISHED BY SnC� idll , 7 (0,- /�17 aU116A 3—l—j COJe,iS GfA& 3Y O O � . Sys!'�,�• 8 3 L CIVA AIL t. I �6 C&jci i4 s S ia�e SEWAGE INSPEC ONS LOCATION '920 Na.in S.tn_eet A DATE 919103 'VILLAGE U�teaviPie, (7a��s. 02655 ASSESSOR'S`MAP & LOT 117-056 INSPECTOR ao,seph P. (7acomge2 a2. SEPTIC TANK CAPACITYl-2000 & 9- 1500 LEACHING FACILITY: (type) 2-Ll?-1000' .6 (sizc) 3000 gaiionz NO. OF BEDROOMS 8 BUILDER OR OWNER0-3te2U-ii.9e Condo {I.6aoc.iation. OWNER MAILING ADDRESS guy Coiiett.i 27 Cottage Lane Cente2v.ii-ee, Nazz. 02632 boo � der r 'h�lE l3aX P4