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Home My WebLink About1112 MAIN STREET (OST.) - Health (2) Ao !'' Y OWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE C. ��-� ASSESSOR'S MAP&LOT //? G213 TN S PIr CTWQ? NAME&PHONE NO. SEPTIC TANK CAPACITY b9— 000 LEACHING FACILITY: (type) 2 (size) mo . NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching ci Feet Furnished by _ � -�s ten' '/ �' �`?7 o � � � -- b. m3-r 1-a j ' Commonwealth of Massachusetts Title 5 Official Inspection Form tI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address ,-- ~ 1112 Condominium Trust � 9 Owner Owner's Name , information is required for every Osterville MA 02648 11/12/2020 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 filling_out=forms A. Inspector Information / 50 3� on thecgrrputer, use or-Iy_the tab Michael T Bisienere key t.o`move your Name of Inspector cursor=_ao not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road to w11 Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938, Telephone Number License Number ;, a, •..',. B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15 340 of Title 5 in. (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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. , t!inspAoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 - -- •,^ate ~'- Commonwealth of Massachusetts Title 5 Official Inspection Form iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address d, 1112 Condominium Trust Owner Owner's Name information is required..for every Osterville MA 02648 11/12/2020 page: , Cityrrown State Zip Code Date of Inspections W— C. Inspection Summary air 1 c.T'ii: 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. r<<,. Comments: i CC.j U`.ii;W iL:•1. - e�T'�3!:.f_._.-_..___ _ 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. r « ,,,s, Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements determined," please explain. io+ 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 f";a.rssN Commonwealth of Massachusetts s Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - -_- 1112 Main Street Units 17-19 - - Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 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. x ❑ 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�wlll 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): 4 7 - ❑ 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: 4 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18xx,; ,fs., Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 17-19 4 . Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water >4 y �, ❑ 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) rl 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**. 5 Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,hfdwfecal 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: Y. 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 f� Commonwealth of Massachusetts "' =<t Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name information is Osterville MA 02648 11/12/2020 required for every - '•-- ••r page..- City/Town State Zip Code Date of Inspections,:', w'tZ:; 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 cesspool is less than 6" below invert or available volume is less than '/2 day flow w rer.... El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS, cesspool or privy is below high ground water elevati_on,_.. ❑ ® 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 ttie analysis and chain of custody must be attached to this form. y `The system is a cesspool serving a facility with a design flow of 2000 gpd- .:...M.�z 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 additionto•the .:=i - questions in Section C.4. Yes No €4,{4 Ic :3r ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts �p Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 �s�~ � ( { Property Address w' , 1112 Condominium Trust Owner`' Owner's Name information is required for every Osterville MA 02648 11/12/2020 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. wi 6. You must indicate"yes" or"no"for each of the following for all inspections: rye; W,r;.$°r a Yes No y ® ❑ 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? ,: a: ® ElWere as built plans of the system obtained and examined? (If they-were,note° 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,. ' ® El 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; R�4; �- ® ❑ 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)] 3 S1�? irtt t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6;of 18 ` ' Commonwealth of Massachusetts �� x Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name information is Osterville MA 02648 11/12/2020 required for every page. Citylrown State Zip Code Date of Inspection D. System Informationd, `' 1. Residential Flow Conditions: ' . Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: = Number of current residents: 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 ^l T' information in this report.) Laundry system inspected? ❑ xYes ❑4=rNo:. Seasonal use? Y II jai ❑ Yes, ❑ .No A Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <}1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 t1/ Property Address a2s 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Warehouse/Office Design flow(based on 310 CMR 15.203): 330 plus GPD Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): q ft/persons « _J t.iM1%I; k F 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 �= In 2019- Water meter readings, if available: 5000 gal and In 2098 50Q0 gal Last date of occupancy/use: occupiedDate -- �F fir Other(describe below): - 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes Z. 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 4, (it Commonwealth of Massachusetts Title 5 Official Inspection Fora ' y a Subsurface Sewage Disposal System Form Not for Voluntary Assessments - 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) �+ 4. Type of System: gar - f _ ® Septic tank, distribution box, soil absorption system , ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ElShared 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 ' -y ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: .,on�^�It Were sewage odors detected when arriving at the site? ❑ YesVip.,,No -'' I _ 5. Building Sewer(locate on site plan): Depth below grade: 24" feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): �. t1 4 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust a wt:';;,;;.- a Owner Owner's Name information is required for:;every Osterville MA 02648 11/12/2020 page-. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"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 1500 gallon Dimensions: Sludge depth: 5" f _ Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumpingco.:. based on the future use of the home. At the time of inspection the liquid level was at working-level. -. 4 c„ and the baffle was in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pag(OQQ9f 68,p-;,.;,pt An ,. Commonwealth of Massachusetts Title 5 Official Inspection Fora I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) >:-�- 7. Grease Trap (locate on site plan): N fi Depth below grade: t - 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 ' t 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.): S j rr 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): w.x > Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons j '` ' '%'• ` 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 i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner' Owner's Name information is Osterville MA 02648 11/12/2020 required for every `_• page. City/Town State Zip Code Date of Inspection u y 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.): ,��malice. , *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 N/A -`` Comments (note if box is level and distribution to outlets equal, any evidence of solids cafryover =any- evidence of leakage into or out of box, etc.): — - I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 s.t - Commonwealth of Massachusetts �n Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osteryille MA 02648 11/12/2020 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 El, No*p 9 ;3 Alarms in working order: ❑ Yes ❑yNo" s Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): F _ If pumps or alarms are not in working order, system is a conditional pass. 14 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): r_-. If SAS not located, explain why: t Type: 1e} K• — ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Teaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1 N , ff= Type/name of technology: :� , _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 e Commonwealth of Massachusetts �= Title 5 Official Inspection Form /I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name information.Wire for Osterville MA 02648 11/12/2020 required for every page.;_ City/Town State Zip Code Date of Inspection i 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.): k At the time of the inspection there was apx 1' of ponding liquid in the leaching pit and no visible failure criteria was found. v. 'N 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ni �.� 1112 Main Street Units 17-19 Property Address -"- 1112 Condominium Trust - Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: a ° - Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): v r w\� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 y _ f VVI-11 Commonwealth of Massachusetts 'Tit1e 5 Official 10spection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1112 Main Street Units 17-19 Property,Address 1112 Condominium Trust Owner—-• Owner's'Name ihforirlation is OsterVille required for every MA 02648 11/12/2020 page: i - City/Town State Zip Code Date of Inspection r° r> D. System Information (cont.) 14. Sketch Of Sewage Disposal System: r- Provide a view of the sewage disposal system, including ties to at least two permanent-,reference w, , 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 _..,.., * , ' a 4 ` q `1 L 1 � J :OC. U '.7. 1 rr. s t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I u 1112 Main Street Units 17-19 Property Address i 1112 Condominium Trust Owner` Owner's Name information is Osterville MA 02648 11/12/2020 required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar I Shallow wells Estimated depth to high ground water: 17 plus feet 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: Date >~ ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: i ❑ Checked with local excavators, installers-(attach documentation) El Accessed USGS database-explain: m, _ You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. -` Before filing this Inspection Report, please see Report Completeness Checklist on next page. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f I Commonwealth of Massachusetts :r Title 5 Official Inspection Form -- I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 17-19 Property Address 1112 Condominium Trust Owner Owner's Name - ref uiread information is Osterville MA 02648 11/12/2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist �ak Complete all applicable sections of this form inclusive of: e �K 11 ® 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 , Ott n,4.it'VvA4; i e P 1 . rrpf Yn. �!'` t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 L Commonwealth of Massachusetts 1/0,013 - il D/ Title 5 Official Inspection Form r� i' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ! V 1112 Main Street Units 5-16 Property Address e 1112 Building r ' Owner Owner's Name `. information is required for every Osteryille MA 02648 10/30/2020 ', page. City/Town State Zip Code Date of Inspection .r Inspection results must be submitted on this form. In forms may not be altered in any way. Please see completeness checklist at the end of the form.. Important:When NA66,jutforms A. Inspector Information olt tR&gomputer, use of&:the tab" Michael T Bisienere t ; key,ta ove your Name of Inspector °" cursor-do not Cape Septic Inspections use the return Company Name key. , Rivers End Road Co � Company Address Teaticket Ma. 02536 Alf City/Town 7 State Zip Code 508-280-3356 - S13938 Telephone Number License Number y B. Certification , I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 &Title5 (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 systerns. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. El Needs Further Evaluation by the.Local Approving Authority - 4. ❑ Failsa t 10/30/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing.thisinspection. 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 r 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. f Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform a "in, in the future under the same or different conditions of use. ,.r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Flo Subsurface Sewage Disposal System Form Not for,Voluntary Assessments 1112 Main Street Units 5-16 Kt Property Address ,F 1112 Building �. 46 �� Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 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 -- 4, indicated below. Comments: y= F 2) System Conditionally Passes: § , ❑ One or more system components as described in the"Conditional Pass" section need to 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 Certlficate.of Compliance indicating that the tank is less than 20 years old is available. z� ❑ Y ❑ N ❑ ND (Explain below): { tsinsp.doa;rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owners Name information is requred'forevery Osterville MA 02648 10/30/2020 f 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 �3d,rvr 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): >'u ❑ 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): . x:.•Jn.i.i i3 L.. ❑ 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): i s. 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page=3'of 18' J_M.. 4 32 .I .y . Commonwealth of Massachusetts �h Title 5 Official Inspection Form pia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 1112 Main Street Units 5-16 Property Address 1112 Building Ownef Owner's Name information is Osterville MA 02648 10/30/2020 required for every page., City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is withinry 100 feet of a surface water supply or tributary to a surface water supply. Page_ ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public:water;-t 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. f c. Other: 4) System Failure Criteria Applicable to All Systems: w,Atl 7 1 You must indicate"Yes" or"No"to each of the following for all inspections: ;. :.`.csr. Yes No El ® 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 n ,^> . Commonwealth of Massachusetts n 6_4 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r u� • 1112 Main Street Units 5-16 ,;.,.. Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 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 cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. w, ❑ ® 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-5,0..feet_... from a private water supply well with no acceptable water quality anaY'sis�[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 whit iff"8b necessary to correct the failure. "°` ``-' fPe 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 El ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking watertsi�pply- X � e'*4n j the system is located in a nitrogen sensitive area (Interim Wellhead Pr"o'tection'- rk fi ❑ ❑ Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v!% 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020r� page. Cityrrown 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 Hea;Ith.F c:'". , t [I ® 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? �...! .�1wr' �-• ® ❑ 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. rya ! ® El Determined in the field (if any of the failure criteria.related to Part Cis at,lssue' Y. approximation of distance is unacceptable) [310 CMR 15.302(5)]' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY c u 1112 Main Street Units 5-16 _ Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: - Y Number of bedrooms (design): Number of bedrooms (actual): n DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): Description: a.. Number of current residents: Does residence have a garbage grinder? ❑ Yes,, 'i No Does residence have a water treatment unit?-, El Yes _Z No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Ta r Detail: F .= Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/36/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: office/warehouse _- 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 " r Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No '~ Water meter readings, if available: In 2019-33,000 gallons used and`2018- a 24,000 gallons used between- all units - Last date of occupancy/use: occupied ----_. ----------- >... Date Other(describe below): 3. Pumping Records: Source of information: -No:- Was system pumped as art of the inspection? Yes ® _ 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 ' c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . 1112 Main Street Units 5-16 � - - - - Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 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 e ❑ 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: Were sewage odors detected when arriving at the site? ❑ Yes ® -.No 5. Building Sewer(locate on site plan): I c<3- ' Y Depth below grade: 11" " Y feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is Osterville MA 02648 10/30/2020 required for every ---- --- --- page. ` Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ---- - 6. Septic Tank (locate on site plan): Depth below grade: 2' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) ------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle 37" Scum thickness Distance from top of scum to top of outlet tee or baffle 511 Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18— Commonwealth of Massachusetts I� Title 5 Official Inspection Fora _ �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ----.N 1112 Main Street Units 5-16 ------------ roperty Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 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 ,< h 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):_ m - Depth below grade: -- - Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): r _ Dimensions: ram..,.,. Capacity: -- - gallons _ Design Flow: i 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 I e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 - - ------- page` Cityrrown State Zip Code Date of Inspection D. System Information (cont.) a_ .._- 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.): , H;1JF? *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ 'No 9. Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids car y ver;,17 y- evidence of leakage into or out of box, etc.): - -At the time of the inspection the liquid level was at working level and there were no visible signs 6f " leakage or solids carryover. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form .. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments oti S:'i.'�w Mks.. 1112 Main Street Units 5-16 V� Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): s Pumps in working order: ❑ Yes ❑-No*=- --- b -� Alarms in working order. El ❑ ' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " I _? * If pumps or alarms are not in working orders stem is a conditional ass. p p 9 Y P 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: Two Y ® leaching pits number: ❑ leaching chambers number: - - ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system `TE a 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is � required for every Osterville MA 02648 10/30/2020 page.. Cityrrown 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.): At the time of the inspection one leaching pit was dry and other pit had apx 12" of ponding liquid and no visible failure criteria was found. C�c'al.iiff 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 f1^IhL. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ------ -- u 1112 Main Street Units 5-16 T ---= -- --. Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 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.): --------------56 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is Osteryille MA 02648 10/30/2020 required for every page.' City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all we lls within 100 feet. Locate where he a public water supply enters the building. Check one of the boxes below: IZ hand-sketch in the area below ❑ drawing attached separately } �..,n _..,....r p 73 2 " • .rat. _ ::.5 :.�-� z, . ... r•. 5 ;.� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form �Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 1112 Main Street Units 5-16 j Property Address 1112 Building Owner Owner's Name information is required for every Osterville MA 02648 10/30/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 17 plus feetfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Yr.. +t 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: �. augered a hole at a lower elevation and shot it with a transit. r fM Before filing this Inspection Report, please see Report Completeness Checklist on next page I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 rt4. I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 5-16 Property Address 1112 Building Owner Owner's Name information is Cisterville MA 02648 10/30/2020 _ required 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 Pa 6.. 4 (Failure Criteria) and 6 (Checklist) completed « xt P- Cie. ® 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts t/9 df 3 —A �.�. Title 5 Official Inspection Fora la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner... E Owner's Name infom atlon is required for every Osterville MA 02648 11/12/2020 page: City/Town State Zip Code Date of Inspection r . .mot✓ 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. Important:When filling out forms A. Inspector Information i on the computer, use only the tab Michael T Bisienere key,to rtlove your Name of Inspector cursor_-do not Cape Septic Inspections use the return Company Name key. 0 "} 52 Rivers End Road --- ,�- Company Address v Teaticket s p,g . Ma. 02536 City/Town State Zip Code -- -- 508-280-3356 . S13938 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 det&m*ined ti s that the system: T.:. _.-._. 1. ® Passes 1 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11/13/2020 In ector'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. „t t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A '1 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 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. r 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described)iY!<. in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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,wilkpass z inspection if the existing tank is replaced with a complying septic tank as approved by the.Board.ofn rA ` Health. rs *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): P. _j -'he Bo am' I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r •t,.. Commonwealth of Massachusetts :. Title 5 Official Inspection Form I? !?� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . � 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust - Ovuner.,_.. Owner's Name info rrriation-is required for every Osterville MA 02648 11/12/2020 - - page. `' 'r . Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box_System will_ h cY1.` 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 i'p`e(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): Ni r n` r�°I:l'2-• LIVE: �,.1:�,lf t9�f - , r_ 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✓,y "ifart:. 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 CHAR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18- i Commonwealth of Massachusetts Title 5 Official Inspection Form ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 1 -4 it Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ti s- ❑ 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 an 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,,� Fa, F, more from a private water supply well**. Method used to determine distance: r **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: 7{t IBC A I f'r t,•A t_ VL = tt Y 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_.. -- y r clogged SAS or cesspool "' + 5 Discharge or ponding of effluent to the surface of the ground or surface waters ❑ ® due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 1 -4 - Property Address 1112 Condominium Trust Owner Owner's Name inform,atlori;is required for every Osterville MA 02648 11/12/2020 page. , CitylTown 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 cesspool is less than 6" below invert or available volume is less than '/z day flow 1V ", Required pumping more than 4 times in the last year NOT due to clogged or r s 1w 1-r ❑ ® obstructed pipe(s). Number of times pumped: ; r ❑ ® 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 DEP1certifed laboratory,for fecal coliform bacteria indicates absent and fhe 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,,ana)_ysis 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 facilifyc, a O. .. r design flow of 10,000 gpd to 15,000 gpd. �- +.r;:-; , For large systems, you must indicate either"yes" or"no"to each of the following, in addition tote° _- ,: questions in Section CA. r 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 kry `jig. I Commonwealth of Massachusetts A Title 5 Official Inspection Form� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " ,vHr3 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is Osterville MA 02648 11/12/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant- r-� threat, or answered "yes"to any question in Section CAabove the large system has failed The ;,, t t 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 aU 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? =3 ® ❑ Has the system received normal flows in the previous two week Have large volumes of water been introduced to the system recentlyfor as part of El N �: * = this inspection? a ® ❑ 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 cons rq iag ,,(` t dimensions, depth of liquid, depth of sludge and depth of scum.?, f s a Was the facility owner(and occupants if different from owner) provided with %' „n: ® ❑ 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)] A r. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 1 -4 V Property Address 1112 Condominium Trust Owner. Owner's Name information,is required for every Osterville MA 02648 11/12/2020 , k page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: a 1 t recw4red fa _ Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: t�. Is laundry on a separate sewage system? (Include laundry system inspection '`? information in this report.) ❑eY_les ❑; No:- Laundry system inspected? ❑ Yes ❑t- No_. Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: x7A I_ k;i:_ Sum pump? OXYds JE Na Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18, t yw 1 } r 4y i Commonwealth of Massachusetts _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3* t 1112 Main Street Units 1 -4 j" tt`$ Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: -� Retail/Office/Warehouse , V �c Type of Establishment: k #- F Design flow(based on 310 CMR 15.203): N/A ' Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): sq ft/persons Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: _ Industrial waste holding tank present? ❑. Yes Z No r = ¢ h Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: In 2019-26,000 gal and in 2018 2;1 000 Last date of occupancy/use: occupied Date Other(describe below): �°a. .� a N JT, 3. Pumping Records: 47 i , Source of information: = Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ,.; t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 t 3 V'- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .u 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name ':p:, =Y•, ti information is Osterville MA 02648 11/12/2020 required for.every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool {,. ❑ Privy cf' e. ❑ Shared system (yes or no) (if yes, attach previous inspection records, f..any� -.,g__.:'!F_._ ❑ 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: _ Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1 T. Depth below grade: feet' Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): e ry ti 'Ore town water Distance from private water supply well or suction line: v t feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments x // SE V„ 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2,l Depth below grade: feet - ._ __ Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years E {' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑t!Yes ❑ No Dimensions: 1000 gallon Sludge depth: 311 Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" - +�t F sludge judge 1 a�, i f No How were dimensions determined? z a a Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integn y,- liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18` �'a' Commonwealth of Massachusetts �n ,9 Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner. Owner's Name information is Osterville MA 02648 11/12/2020 required for every -- - --- page„ Cityrrown 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): "ul!F.0 F'. --.- - - - - � � 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 El fiberglass ❑ polyethylene ❑:other(explain):- - r.4 r 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 u 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 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.): Y *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes _ 0 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. •.is :...-Y�-a•.. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 i t . Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 page:..• t Cityrrown State Zip Code Date of Inspection. D. System Information (cont.) F y .v 10. Pump Chamber(locate on site plan): t`' AL Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): • k * 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: --- ---- - it y Type. ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: Elleaching trenches number, length: µ -- ❑ leaching fields number, dimensions: ; :µ V ❑ 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 n .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1112 Main Street Units 1 -4 - Property Address 1112 Condominium Trust Owner` Owner's Name information is required for every Osterville MA 02648 11/12/2020 page. Cityrrown 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.): At the time of the inspection there was apx 2'of ponding liquid in the leaching pit and no visible failure criteria was found. 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.): ti t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville MA 02648 11/12/2020 pager 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.): Ham. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official InSpection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner{ Owner's Name id4Uiredfore Osterville MA 02648 11/12/2020 r'equired�for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) -- Ta 14. Sketch Of Sewage Disposal System: - "r Provide a view of the sewage disposal system, including ties to at least two permanentreference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately - - i i k M1 " 1 s,, yr r;,; 'S /* sg (jY- otter�. < *4 4 . ytt '��"�-��r..�..e�^... .-. - _ _.... r.. ... _r. �,_ "- .`. .-.......yam. - ......... ...,.+.1,•..--.-.: a `t5i4411•rev.7/2612018 Tito 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 sp Commonwealth of Massachusetts Title 5 Official Inspection Form Fie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is Osterville MA 02648 11/12/2020 required for every , page:.-.-.;. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r� 15. Site Exam: t; ol , T ,u ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 17 plus feet feet Please indicate all methods used to determine the high groundwater elevation: - _ ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date f ® 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) z ❑ Accessed USGS database-explain: - i � 1 You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. 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 r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is Clsterville MA 02648 11/12/2020 required 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: Owner ,.f"ar) 0 1 2, 3, or 5 completed as appropriate ; i p 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 cn pg. 16 or attached ` For 15: Explanation of estimated depth to high groundwater included M xr,;, - i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 .,i.' 6. r Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s.•'' 1112 Main Street Units 1 -4 0 Property Address n 1112 Condominium Trust Owner Owner's Name information is �/ required for every Osterville Ma. 02648 09/29/2016 page. City/Town State Zip Code Date of Inspection t-+ Inspection results must be submitted on this form. Inspection forms may not be altered in am way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Ins ector key: p Cape Septic Inspections Company Name 624 Old Barnstable Road �I Company Address Mashpee Ma. 02649 Cltyrrown State Zip Code 508-280-3356 S13938 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent 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•3113 Title 5 Official Inspection 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 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner information is Owner's Name required for every Osterville Ma. 02648 09/29/2016 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: 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•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r .� Commonwealth of Massachusetts Title 5 Official Insp ection p n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 ` 09/29/2016 page. Cltyrrown 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 pipes)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 quired 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 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust '. Owner Owner's Name information is OSterville+ required for every Ma. 02648 09/29/2016 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 cesspool is less than 6" below invert or available volume is less than '/day flow 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 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 09/29/2016 page. CltyfTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No {❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a`surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim`Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system'is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name - information is required for every Osterville Ma 02648 09/29/2016 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 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 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner information is Owner's Name required for every Osterville Ma. 02648 09/29/2016 a e. Clt own p /T g y State Zip Code Date of Inspection D: System Information Description: Number of current residents: 0 Does residence have a garbage grinder? Y❑ es ❑ No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ❑ No Laundry system inspected? ❑ Yes .❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office/Warehouse 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 f , Commonwealth of Massachusetts~ Title 5 Official Inspection p on Form_ . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner ' Owner's Name information is OSteNille required for every Ma. 02648 09/29/2016 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:. ' Was system pumped as part of the,inspection? ❑ Yes ® No If yes, volume pumped: gallons - How was quantity pumped determined? Reason for um in f. P P 9� . a Type of System: 4. x , ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy j . ❑ 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 't 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 09/29/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on,site plan): Depth below grade: , 11" 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.): Septic Tank(locate on site plan): •Depth below grade: 211feet 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: Standard 1000 Gallon Septic Tank Sludge 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 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 09/29/2016 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 39" 1 Scum thickness < „ Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? field instruments Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t . 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 u,�•°' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 09/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time.of inspection) (locate on site plan): Depth below grade: . Material of.construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity:P tY: 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 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 09/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution,Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At the time of the inspection there were no signs of past hydraulic failure 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 , 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma. 02648 09/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: one ❑ 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.): At the time of the inspection there was appx. 1 foot of ponding water in the leaching pit and there were no signs of past hydraulic failure. k Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration { 9 Depth—top of liquid to inlet invert Depth of solids.layer Depth of scum layer ' Dimensions of cesspool f Materials of construction Indication of groundwater inflow ❑ Yes ❑ No i . t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1112 Main Street Units 1 4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma., 02648 09/29/2016 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): M. Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 1 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every OStervllle Ma. 02648 09/29/2016 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 - C-1 � t 1. i cc/ Z A2 �'xd' 132 '33' r r C4-4s° V4 3i,6 �G Cis r i°- r r i �..r Commonwealth of Massachusetts ,. Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name iro isrequired for every Osteryille Ma. 02648 09/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water:- 17 plus feet 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: 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: I augured a hole at a lower elevation and shot it with a transit 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 , t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1112 Main Street Units 1 -4 Property Address 1112 Condominium Trust Owner Owner's Name information is required for every Osterville Ma 02648 09/29/2016 . page. Cltyrrown. State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked n '' ® 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 ALU � v t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 17 of 17 t ,