HomeMy WebLinkAbout0105 PARKER ROAD UNIT BLDG 1 UNIT A - Health (2) i 05 Parker Road (Fairways at Wianno)
Osterville
A,.= 11.6=030
v 10 2015 23:48 Jim The Inspector Man 5085349919 page 1
Commonwealth of Massachusetts /V - 03o Zyz),4
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno) '' t
Property Address
fill
First Property M mt. :r>
Owner Owners Name
information is
required for every Osterville MA 02655 11-9-15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, 1�z(Q� %Olnp����
use only he tab `� ��`���ZN OFS
1. Inspector: �.��:'• • Sq 4�
key to move your �.;' • • • �y
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use the return .lames D.Sears �: JAMES
key. Name of InspectorSEARS a
CapewideEnterpries, LLC Ar
dfl,a 11 Company Name T I F
153 Commercial Street
Company Address M.
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
e
actor'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 Inspeclion Form;Subsurface Sewage Disposal Systen•Paga
Nov 10 2015 23:48 Jim The Inspector Man 5085349919 page 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Road(Fairways at Wianno)
Property Address
First Property Mgmt
Owner Owner's Name
Information Is required for every Osterville MA 02655 11-9-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 4500 Gal.Tank D Box and four pits.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old'or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
M a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I .
Nov 10 2015 23:48 Jim The Inspector Man 5085349919 page 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owners Name
Information is
requiredfor every Osterville MA 02655 11-9-15
page. City/Town State Zip Code Date of Inspection
B. Certification (Cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ 'Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health,
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment:
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland ore salt marsh
t5ins-3113 Title 5 Olfidal Inapeclion roan:Subsurface Sewage Disposal Systen•Page 3 of 17
Nov 10 2015 23:48 Jim The Inspector Man 5085349919 page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is Osterville MA 02655 11-9-15
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No" to each of the following for all Inspections:
Yes No
❑ Backup of sewage into facility or system component due.to,overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in mane d is less than 6 below invert or available volume is less
than %day flow P/r
t5ins•3113 Title 5 Official Inspection Form!Subsurface Sewage Disposal System Page 4 of 17
Nov 10 2015 23:48 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Properly Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-g-15
page. CityrrDwn 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.
15ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 ,.
Nov 10 2015 23:48 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owners Name
Information is Osterville
required for eve MA 02655 11-9-15
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): 16 Number of bedrooms(actual): 12
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 0 of bedrooms): 1760
151ns 3113. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page Sot 17
Nov 10 2015 23:49 Jim the Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno
)
Property Address
First Property mgmt.
Owner Owner's Name
information is required for every Ostervllle MA 02655 11-9-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
the system is a 4500 gallon tank D Box and four leaching pits
n
Number of currenta
residents.
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection " ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readin s, if available last 2 ears usage 2013-113,000Gal
g ( y g (gPd))' 2014-122,000Gal's
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: Present
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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: -
15ins•W 3 Title 5 Official Irspectlan Foam:Subsurface Sewage Disposal System•Page 7 of 17
Nov -10 2015 23:49 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-9-15
page. City/rows 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 pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a,copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe)-.
l5ins•3/13
Title 5 Official Irspectlon Farm.Subsurface Sewage Disposal System•Page 8 0117
I , Nov 10 2015 23:49 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-9-15 page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1988
Were.sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 10"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: 4500 Gal precast H-10
Sludge depth:
2"
15ins-3113 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Nov 10 2015 23:49 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Road (Fairways at Wtanno)
19, -
Property Address
First Property Mgmt.
Owner Owner's Name
Information is required for every Osterville MA 02655 11-9-15
page. CityfTown 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
40"
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
32"
How were dimensions determined? Asbuilt-Tape
Past Report sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank pumped yearly. Tank at 10" below grade H2O w12 inlet tees. outlet tee . no sign of leakage
or overloading
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
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
151ns•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Nov 10 2015 23:49 Jim The Inspector Man 5085349919 page 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s 6 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°f 105 Parker Road (Fairways at Wianno
Property Address
First Property Mgmt.
Owner Owner's Name
information is
required for every OStervllle MA 02655 11-9-15
page. Cilyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons ,
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc,):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Nov •10 2015 23:50 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 18"46"w/steel cover at 18". Box is clean and solid w/four lines out. No sign of over
loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
151ns 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 or 17
Nov 10 2015 23:50 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
required for
is every
Osterville
required for eve MA 02655 11-9-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 4
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four precast pits wsteel covers at 6" below grade. Stain line's at 2'to 30". No sign
of over loading or solid cagy over. Pits 2+3 dry, Pit 1 20"water, Pit 4 6"water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
` Materials of construction
I
Indication of groundwater inflow ❑ Yas ❑ No
t5ins•3113 Title 5 Official Ineoecton Form:Subsurface Sewage Disposal System•Pape 13 of 17
I, Nov •10 2015 23:50 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt
Owner Owner's Name
information is required for every Osterville MA 02655 11-9-15
page, CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Thle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Nov 10 2015 23:50. Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
16ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Nov •10 2015 23:50 Jim The Inspector Man 5085349919 page 16
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Nov •10 2015 23:50 Jim The Inspector Man 5085349919 page 17
N, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Road (Fairways at Wianno)
Property Address
First Property Mgmt
Owner Owner's Name,
information is required for every Osterville MA 02655 11-9-15
page. City/Town State Zip Code' Date or Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N ,
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1988
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:
Hand Auger 12' no water. Auger 4' below bottom of pit
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3113 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal Syslem-Page 16 or 17
Nov 10 2015 23:51 Jim The Inspector Man 5085349919 page 18
commonwealth of Massachusetts
Title 5 Official Inspection Form
U.69
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker R
oadd (Fairways at Wianno)
Property Address
First Property Mgmt,
Owner Owners Name
information is OSteNIIIe
required for every MA 02655 11-9-15
page. Cityrrown State Zip Code Date of,Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•3/13 Tltle 5 Official Inspec tlon Form:Subsurface Sewage Disposal System•Page 17 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-12-12
,_.
page. Cityfrown 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:Whenfill ng out fornis A. General InformationNI
46,
,�►++1lddrdndlr
on F the computer, `\`gNtH OF lygs ����
use only the tab 1. Inspector: �(
key to bo move your =.��c�' JAMES N
cursor-do not James D. Searsuse
the return Name of Inspector ; SPARS
* c
Capewide Enterprises, LLC % �'•o o:
Company Name /��-�S�I N SP G ��
153 Commercial St. ����'►nrrrunm�t�`����
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone.Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system.inspector pursuant to Section 15.34.0-of
Title 5(310 MR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
[] Needs Further Evaluation by the Local Approving Authority
11-12-12
spector's signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design Flow of 10,000 gpd or greater;the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
*'""This report only describes conditions.at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in.the future under
the same or different conditions of use.
/ZoIU
151ns-11/10 TIUe5ofrlde! 2.au tab,malaCe Sewage Disposed System-Page 1 M 17 ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is Osterville MA 02655 11-12-12
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
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 fnilowing 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 extiltration 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):
f51ns•i vfo rule s omcial Ins pedbn Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
O
Owner : —
Owner's Name
information is required for every Osterville MA 02655 11-12-12
page_ Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
. B) System Conditionally Passes (cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and,the environment:
❑ Cesspool or privy is within 50 feet of a surface water
' ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.-11110 - Tith 5 DIfcW rnsyection Forth;Smbsurface Sewage Disposal System•.Page.3of.V
Commonwealth of Massachusetts
itle 5 official Inspection Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
19-1
105 Parker Rd. (Fairways at Wianno
PP operty Address -
First Propeq M mt
Owner 0 vnef's Name
information is required for every C sterviile MA 02655 11-12-12
page. clyfrown State Zip Code Date of Inspedion
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,H 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 wager 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 fee_t 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
Q Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in qgspmW is less than 6"below invert or available volume is less
than Y,dayfl ow /SIT
sins•11/10 Title 5 Olfldal Inspecfiw Farts:Subaurtace Sewage D4ml System•Page.4 o(17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every: Osterville MA 02655 11-12-12
..
page. Citylrown State Tip Code Date of inspection
B..-,Certification (cons.)
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 15303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to:any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Sectoon D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
151n9.1111 Thin 5 Ortidar Inspection Foam:Subsurface Sewage Disposal System-Aage S of 17
Commonwealth of Massachusetts
lug, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmf.
Owner Owners Name
information is Osterville MA 02655 11-12-12
required for every
page. cityrrown State Zip Code' Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board.of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the,site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The sae and location of the Soil Absorption System tSAS)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 Conditlons:
Number of bedrooms(design): 16 Number of bedrooms(actual): 12
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1760
t5ris-11110 Title 6 Official I:speetlon Form;Suheurfmo Sewage Disposal System•page 6 a117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt_
Owner Owner's Name
information is Osterville MA 02655 11-12-12 requiredd forevery ,
page. Ctty/rown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 4500 gallon tank, D Box and four leaching pits
Number of current residents: unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): 2010-171,000Gal
2011-167,000Gal
Detail:
�
I
Sump pump.
❑ Yes ® No
Last date of occupancy: Present
Date
Commercialandustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatstpersonslsq.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:
t51ns•11/10 Title 5 Mid Insyedion Forth:subsurface sewage Disposal system•Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'y 105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information's required for every Osterville MA 02655 11-12-12
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of_inforrnation: -•- --
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: _
Type of System:
® Septic tank, distribution box, soil absorption system
Single cesspool
❑ Overflow cesspool
Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
0 Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the IJA system by system operator'under contract
❑ Tight tank.Attach a copy of the CEP approval.
[] Other(describe):
l5ins-1 V rO THIe 5 Official In apeclion Form:Skbsurfaoe Sewage Disposal Sysem•Page B of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
infom, for every ad is
required for Osterville MA 02655 11-12-12
page. Cityrrown State Vp Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet -
Material of construction:
❑cast iron 040
PVC ❑ other(explain):
Distance from private water supply well or suction line: 10'+
feet
Comments (on cond'Rion of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes ❑ No
II 4500 Gallons
Dimensions. .
21t
Sludge depth:
' I
Mins•111110 Title 5 Of dal Inspedien Fort:SubUOaca Sewage Dlsposat System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Foam-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt
Owner owner's Name
information is,
required for every Osteniille MA 02655 11-12-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
40" �
Scum thickness 3„
g„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 2W
How were dimensions determined? Asbuilt TapePast Report
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tannk pumped yearly,Tank to be maint pump after inspection, Tank at 10"below grade H2O w.
!covers at 6",outlet tee, No sign of leakage or over loading
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
t
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: ate
15ins•11110 Me 5 Official trupecilon FomK Suosudace Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Proper Mgmt.
Owner Owner's Name
Information is Osterville MA 02655 11-12-12
required for every
page. Citylrown state Zip Code Date of Inspection
E: -
D. Systefff Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ElYes ❑ No
sins•11110 Tille 5 official Inspection Forth:Stbsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at wanno)
Property Address
Owner First Property Mgmt
information is Owner's Name
information .required for every, Ostervilte MA 02655 11-12_12
page. CitylTown —Zip Code Date of Ins pectan
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x36" w/steel cover, at 18" Box is cleen and solid w/four lines out, No sign of over
loading or solid carry over
Pomp Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No
Alarms in working order ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
15ins-11Ha
Twe s Omaar 6nspectlan Form:suosurtwo sere orsposw system-Papa 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt
Owner Ownees Name
information is required for every Osterville MA 02655 11-12-12
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cost.)
Type:
® leaching pits number. 4
leaching chambers number:
C leaching galleries number.
[] leaching trenches number, length:
leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovativetalternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four precast pits w/steel covers at 6"below grade, 1'water in pits, stain line's
at Zto 30", No sign of over loading or solid carry over
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert --
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
I Materials of construction
Indication of groundwater inflow D Yes ❑ No
15in8 11110 Title 5 OffKtl Inspection Fom Subsurtew Sewage Disposa System•Page is cr 17
. Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt
Owner Owner's Name
information is required for every Osterville MA 02655 11-12-12
page. City/Town State Zip Code Date of Inspection
D. System Information (Cont)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc,):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).
I
15ins•11110 The 51hGctal Irmimiron Form:&t Wsce Smge Mpowl System•Page 14 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is Osterville MA 02655 11-12-12
required for every
page. City/Town State, Zip Code Date of Inspection
D. System Information (cunt.)
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 fleet Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
I
t5ins•11110 Title 5 offidW rnspection Form:Subsudace Sewage Dlaposm System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Parker Rd. (Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
informrequired
is Osterville MA 02655 11-12-12
required forevery
page. Cityrrown state tip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1988
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:
Hand Auger 12' no water, Auger 4'below bottom of pit
Beforefiling this Inspection Report,please.see Report Completeness Checklist on next page.
t5ins•11110 ! Title 5 Official Inspection Form:Subsurface se"99 Disposal system-Peae 16 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd..(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-12-12
page. Citylibwn State Zip Code Date of Inspection
E. Report Completeness Checklist
®9 Inspection Summary: A, B,C,D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 The 5 Official Inspedion Form SLbsurfaca Sewage Disposal System-Page 17 of 17
_
1 '� t - F T�•"j � �
��[s3 •�
t
s r o »r
is• ��
t'
1 1 1 • �. .I 11 • —
. .
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e;M 105 Parker Rd. Fairwa s at Wianno
( Y )
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the4- 2
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterpdses,LLC.
Company Name
rab P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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 f
Title 5(310 CMR 15.000). The system: u Q
® Passes ❑ Conditionally Passes ❑ Rails �� a
k" f -M
❑ Needs Furt er Evaluation by the Local Approving Authority Ct-
emi a, -
is
6
10/16/2009
Ins ect is Si to 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
a
s
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
q 105 Parker Rd.(Fairways at Wianno)
M
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
71
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
h ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Il
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every 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 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 Y2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M a`' 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 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
j If you have answered "yes"to any question in Section E the system is considered a significant threat,
I 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
I system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every 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): 16 Number of bedrooms (actual): 12
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1760
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i -
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 4500 gallon tank,D-Box and four leaching pits.
Number of current residents: Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/16/2009
Date
Commercial/Industrial Flow Conditions: ,
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every 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: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 4500
gallons
How was quantity pumped determined? Measured
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system-operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System vented through the house vents.
Septic Tank (locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
h
Dimensions: -4500gallon
Sludge depth: 0
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Tank pumped at time of
inspection.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank yearly.lnlet and outlet tees are in place-.No evidence of Ieakage.Tank appears structurally
sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
.Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has four outlet Iaterals.No evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 4
❑ 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.):
Sandy soil.No signs of hydraulic failure.Pit#1 water to invert 5'.Stain line 4'.Pit#2 water to invert
4'.No stain line higher.Pit#3 water to invert 50".Stain line 46".Pit#4 water to invert 54".No stain line
higher.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
Town of Barnstable Geographic.Information System
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 14.3'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: 1988
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:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Parker Rd.(Fairways at Wianno)
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for Osterville Ma. 02655 10/16/2009
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
�A,�wgryS L JAnno
TOWN-OF BARNSTABLE
�LOCAdt:iN
!oS" pi9rke/ Rd SEWAGE #
LAGE OsTerv, ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE/NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) G X ' ' S (size)
NO.OF BEDROOMS Ia-
BUILDER OR OWNER Q LL/J CQ^GQ ASS'-
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac ng facility) Feet
Furnished by L/Q Sgi�Qn
ire-a•�'r '
A# .
A 3+ SSr�O ^ N3- 5y.�
'A,f--1 ~ S`o
AS-_ IOY
A 7 IMP
S �
�J5 TOWN OF BARNSTABLEgryt '
Lam?r_ a
C3CAT'O?V SEWAGE #
.1LLAGE n C i�tV��®\�� ASSESSOR'S MAP & LOT
-tea
INS-1 ALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS k` —
BUILDER OR OWNER 'V kQI,rX L; prSS0 C,
DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Tablet '' ty ZU Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 6 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) i Feet
Furnished by_�7.c e`—)
micas• .
Oki
IE-L' 8y ' �bsn
�' 3 7010' "60`
� O O
" LOCAT10 SEW GE PERMIT 'NO.
Ids PAR ker
,VILLAGE
U(((e
IN A LLE 'S NAMES A ADDRESS
S ) Ak
BUILDER OR. OWNER
5
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED -:.� _�
o
h.
1 '
No........ ... LO - 0310 ~ i s
Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH]
'OtU1�..-... ......OF......... ��..
Appliration for Disposal Works Tonstrurtion Prrmil
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Locl ----��.�A'—/-A /frrl4S7cf-4
.....................................................
Locatio -Addre or Lot No.
_7 -----.wl�Gl�z�x si�r�l /t..._....
Owner Address
......... n-•----- .(.. -------------------------------------------------------------------•••---
/J Installer Address
UType of Building (/ Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .....4� ------------ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherf'xtures ------
W ------ -------•--------------•-•--------..............................................
.�
x Design Flow_.____ ..0 . aIlons per person per day. �
..... y � _..... ..._._.........___.___._....gallons.
WSeptic Tank—Liquid capacity------------g<llons Length................ Width---------------- Diameter---------------- Depth..--__-______---
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit NO........
Diameter-------3®q-__- Depth below inlet................ . Total leaching area..----_--___------sq. ft.
Z Other Distribution box ( ) Dosing�nk ( ) LC-/YGIv�y /�/7f'
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water._-_.___-_-__---__--_-_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-__-__-__-_-____---.
Da' --------------------------------------------------------------------------------------------•-.-- --------•-•------------------------------------------
Description of Soil �.._� 4...:..y��'e �C1C.L--•-•••--•--•-----------•-----------•--•••......---•-----------• ------
M --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ooU
U Nature of Repairs or Alterations—Answer when applicably_________y,__ _ ____.... _ti� ' _l�A'��.._____.______.___.____.--.
---------------------------=� JP_-_...
------------------
U A y ��o o- T- L _d!c�oi�c ------------------------
=-------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued th b rd of heal*.
S 3- 7Signed----- - -
l Date
Application Approved BY :.1_� sf1�/e .. '�'�ole ------
Date
Application Disapproved fo the following reasons:.......................................................................................----Dat.e..............
--------•-------•----------------•--------•-•----_------------•---•-----------------------------------•----------•---------------•-•----•--••--------••-------••-•----------•-------•-----------•--
Date
PermitNo..----.3p y--•-•--•--•---••---••••....... ...... Issued......�f------------------------....................
Date
- .. M{��.{{•111{�.n111�{��'�Y�'{-{{'1'!'{..►{1�{11�1'JO{I���{{1-{YY-{�101{I.11�-{.11..�{1..t-{'-.1.{-�.1,�.{{.�.{Fu.&..o L6..1{1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....
-J...-.� l' ................
TUrdif ira#le of
THIS IS TO CERTIFY, thg Indivi ual Sewage..Disposal System constructed (1,<or Repaired ( )
Installer _ n A
at •-•---•-........ l.1_Gf----��( --•---1-- ?s - 1. t-- ._ rye-r' -6 ....[ .'--t- �S i�------
has been ins lied in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated_.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,
DATE................................................................................ Inspector....................................................................................
THE FOLLOWING
IS/ARE THE- BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I m A-
DATA
No.----•.,x-rt fir..--- Fxx..-` .. ' ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.� C)_(ef A ........ OF...... �" -� ..'....ft ?.�. �.-+ 1?:'•. "--.-.-....
Applira#ion for 'inpooal Works Tonn#rur#inn Prrutit
Application is hereby made for a Permit to Construct (. ) or Repair ( ) an Individual Sewage Disposal
System at:
,r"'f'r% ,uw lirl d� !.` �l A d: f:'_E �.
..... ........ ............................................................ ............... ......................... .___. ____________—__ ____ ._______.-
Location_AddressX or Lot No.
, Owner ` Address
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__.............______-----------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building lam"". __. No. of ersons____________________________ Showers
a YP g - K•• P ( ) — Cafeteria ( )
Otherfixtures ------------7- -...........................'•----------------------------_____--------------------------__------ ----------
W Desi n Flow__________ _l ............................ allons er erson er da Total daily flow______r.__.'��<'._`'....................gg� P P P Y• Ygallons.
WSeptic Tank—Liquid capacity_'?-::".....gallons Length________________ Width---------------- Diameter---------------- Depth_---______...--_-
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No....... __________ Diameter_______Q Q____ Depth below inlet____________________ Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosingi:tiank ( ) i_`,,Yj k
a Percolation Test Results Performed by -----•--•••----•--•--•-- Date
Test Pit No. 1................minutes per inch Depth of "Test Pit.................... Depth to ground water__-___-_______________.-
t� Test Pit No. 2................minutes per inch Depth of Test Pit.. ..:_._..::::__:.. Depth to ground water________------:________
0 Description of Soil.................-CAA---F =. - `
.r
U -----------•-------------------------------
W
VNature of Repairs or!Alieraiions'=—`An wer when applicable,_______ " r_r_f___._._�' A �" _ � X
............................'_"_'_'----...........'_'___5------------------r"•'-"""-'-` __-____-----•-•--------
Agreement: 1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b Ord of heayk.
Signed...... f J a S
s y' Date
Application Approved By.. r' .................. ' ` t --'x r
................ ----------------------------------------
Date
Application Disapproved far the following reasons:...........................................................................................................
•-------•-'----------•-------------..----------------'----------------------------------------------------------
Date
Permit No.......�_?_ ::'
....................................... Issued.......`
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AT
wi n#ifira#r of Tontplianre
THIS IS TO CERTIFY, Tl , the Individual Sewage D sposal System constructed (, '"or Repairedby ( )
------------
+� ' Installer t / g}
at. -'" •"'s a� 1 _E9 ¢r rd C� ° i_ +,r a' M P 1 bv.f
.,�.um.w.. yr
__ .__. _. i_T _�_.__S
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
'DATE............................................................................... Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
2 f '' ';..',..l..t ...... ..OF--.-. ;��*s:!� - � .!'' -?..
---•----•---..
NO ?_. ,........ FEE....... _._ .' :..
�i��o,��l nrk� C�on�#nnr#inn ennti#
Permission is hereby, granted_________:, `
to Construct ( )015r Repair ( ) an Individual Sewage Disposal System
r
'" �'4.✓° /`e-1 i� Sit✓=�f cif.. .
at No. r+ P_1: `_.f' '�'§-•''------...__r __'3 ------•-----.. r
---------------------------------- ---------------------
Street
as shown on the application for Disposal Works Construction Permit No ` ------- llated_____ ____ ........ I
.................. -----------------------------------------------of Health
DATE---------------------------------•--
e see ,
: x
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - - -