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HomeMy WebLinkAbout0171 PINE LANE UNIT UNIT 1 - Health 171 PINE LANE (UNITS A-D) Osterville A = 117 — 058 — 20A through -20D ` i G TOWN OF BARNSTABLE 1:OCATION 1 / �O ROB �'�' SEWAGE # L" VILLAGE ST ASSESSOR'S MAP & LOT //NS,0tcT,ev INSTA&&M NAME&PHONE NO. �� �� � 91) �o 0 SEPTIC TANK CAPACITY �TTEACHING FACILITY: type) (size) NO. OF BEDROOMS S U b�iJII.DER,OR 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet 44 Furnished by L A W Y o7' � Y W� O 1 y N � Commonwealth of Massachusetts I Imo-05g—a 014 Title 5 Official Inspection For — h! Subsurface Sewage Disposal System Form - Not for Voluntary lr Y y Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS 11 CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE _ _ MA 02655 _ 4/20/2021 required for 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 A. Inspector Information 3� filling out forms I� �5 on the computer, use only the tab Christopher Maki key to move your Name of Inspector -- cursor-do not Cape Cod Septic Services use the return Company Name -- -- -- key. 350 Main St. _ 4Q Company Address W Yarmouth _ _ MA _ 02673 City/Town State Zip Code rzlW� 508-775-2825 __ _ S1-14423 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 ins ected the sewage dis posal 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 5/10/2021 _ nspector's Sig ture 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 in 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. l5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Y Commonwealth of Massachusetts Title 5 Official Inspection Form �1; Subsurface Sewage Disposal System Form - Not for Voluntary y Assessments c. 171 PINE LN UNIT 1, UNIT_2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION _ Owner Owner's Name - `— information is OSTERVILLE required for every _ MA 02655_ _ 4/20/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist..Any failure criteria not evaluated are indicated below. Comments: ` SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is.available. ❑ Y ❑ N ❑ ND (Explain below): 15insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts `�s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT-3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is __ required for every OSTERVILLE _MA _ _02655 4/20/2021 page. City!Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of'Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in.a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Igo Title 5 Official Inspection Form _ it Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION— Owner Owner's Name information is OSTERVILLE MA 02655 4/20/2021 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 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. j ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments : L 171 PINE LN UNIT 1, UNIT 2, UNIT 3 _ Property Address CLOCKWORKS_II CONDOS ASSOCIATION Owner Owner's Name _ information is required for every OSTERVILLE __ _MA_ 02655_ 4/20/2021 _ _ _ _ _ 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well.. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The. system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 16) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address _ CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is required for every OSTERVILLE MA 02655_ 4/20/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ;p Title 5 Official Inspection Fora �) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION _ Owner Owner's Name information is OSTERVILL_E MA _ 02655 _ 4/20/2021 required for every __ _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 12 Number of bedrooms (actual): 12 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 Description: Number of current residents: UNKNOWN Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to:Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage N/A 9 ( Y g (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 r Commonwealth of Massachusetts , _l(p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address - CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is y OSTERVILLE _ required for ever _ MA _02655 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: --- - - — Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: pate Other (describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? -- Reason for,pumping: l5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ; Title 5 Official Inspection Form . _ 8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /r 171 PINE LN UNIT_ 1,_UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE MA 02655 4/20/2021 _ required for every _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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: TANK & LEACH UNKNOWN. DISTRIBUTION BOX REPLACED IN 2015 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer (locate on site plan): Depth below grade: 5 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.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 .� Commonwealth of Massachusetts I Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION _ Owner Owner's Name - information is OSTERVILLE _ MA 02655 4/20/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 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) ❑ Yes ❑ No Dimensions: 2500 GALLONS Sludge depth: 6" / Distance from-top of sludge to bottom of outlet tee or baffle --- Scum thickness 3 _ Distance from top of scum to top of outlet tee or baffle — — Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc'): 2500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS ARE AT GRADE ON RISERS t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT_ 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name ---- -- -- -- _ information is OSTERVILLE _MA 02655 4/20/2021 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: --- Scum thickness — Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle -- Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank'must be pumped at time of inspection) (locate on site plan): Depth below grade: - -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: -- - - - gallons Design Flow: gallons per day t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts s Title 5 Official Inspection Form I" Subsurface_Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is required for every OSTERVILLE _____ _ _MA 02655 4/20/2021 _ page. City/Town _ State Zip Code Date of In D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: — — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts � w� Title 5 Official Inspection For i l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is MA 02655 4/20/2021 required for every OSTERVILLE _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on'site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 — ❑ leaching chambers number: — ❑ leaching galleries number: = ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts � a . Title 5 Official Inspection Form p. { ye. ,i Subsurface Sewage Disposal System Form Not for Voluntary Assessments =, 171 PINE LN UNIT 1, UNIT 2, UNIT 3 _ Property Address - - CLOCKWORKS II CONDOS ASSOCIATION_ Owner Owner's Name information is OSTERVILLE _ required for every _MA_ 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-PITS FOUND WITH V OF EFFLUENT DURING INSPECTION WITH NO EVIDENT STAINING. COVER IS AT GRADE 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 712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1', Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 11 U_ NIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name -- information is OSTERVILLE _MA 02655 4/20/2021 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: — -- Dimensions Depth of solids — - -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.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 171 PINE LN UNIT 1 UNIT 2 UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name---�-- - — information is required for every OSTERVILLE _MA 02655 4/20_/2021_ _page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts - 1 Title 5 Official Inspection Form '= _ r Subsurface _�, > Sewage Disposal System Form Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address — -- -------- - - —--- CL_OC_KW_OR_KS II_C_O_NDO_S ASSOCIATION Owner Owner's Name i on isrequired for every OS_TERV__L.L__,_________ MA_ _ 02655 4/20/2021 _ 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: +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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health- explain: PRIOR REPORT ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: TEST HOLE DATA PER PLAN ON FILE AT BOH. REFERENCE PRIOR INSPECTION REPORT r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 . Commonwealth of Massachusetts 1�-- IyP Title 5 Official Inspection For i�) Subsurface Sewage Disposal System Form Not for Voluntary Assessments 171 PINE LN UNIT 1, UNIT 2, UNIT 3 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is required for every OSTERVILLE _MA 02655 _ 4/20/2021 — _ _ _ _ _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 7 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 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 r -off er+C �Q.AIPGPIPNF$ M _ - Rrsr�NCL�S rN b+EcrAibZ FEED 8 E•�QS'll1 � A 9 s BUR L D. ING 0 96.8 trNrr ; UNIT 4 i UNIT 3 jt,. .. .. 3 . .. Not E To 9600 Pq40N.SEPTIC TANK .SGAL,E PAVED DAI VEWA LEkW IPIY .rp.� P1T D Dbx VEOETATED AREA ti II Y Y V L'_-m. {may A NE }7um , .508 364- 0894 r N � Commonwealth of Massachusetts Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,; L 171 PINE LN UNIT 4 r ' Property Address r. CLOCKWORKS II CONDOS ASSOCIATION py Owner Owner's Name information is ✓ r; required for every OSTERVILLE _ �^ MA 02655 _ 4/20/2021 page. City/Town State Zip Code Date of Inspection e. 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 on the computer, use only the tab Christopher Maki_ key to move your Name of Inspector - cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main St. _ raa Company Address W Yarmouth __ _ MA _ 02673 City/Town State Zip Code reran 508-775-2825 _ SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/10/2021 ., --- nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 i Commonwealth of Massachusetts 1= _ lrp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c, f Y � 171 PINE LN UNIT Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name required for is y OSTERVILLE _ required for ever MA_ 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 r Commonwealth of Massachusetts ,g� Title 5 Official Inspection Form t1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address CLOCKWORKS II_CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE _ _ _ required for every MA 02655 4/20/2021 page. City/Town ^� State Zip Code Date of Inspection C. Inspection Summary (cont) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 �. Commonwealth of Massachusetts NSrw� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 u Property Address — CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE _MA 02655 . 4/20/2021 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 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 of a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts fy Title 5 Official Inspection Form I I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 _ v _ Property Address —" CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name A — information is OS_ _ required for every O TERVILLE _. MA _02655 4/20/2021 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 El ® than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CVO\ e� 171 PINE LN UNIT Property Address — CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is required for every OSTERVILLE __ MA 02655 4/20/2021 __ _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C,5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ it Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments c; � 171 PINE LN UNIT 4 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is _OSTERVILLE { MA _ 02655 _ 4/20/2021 required for every _ _ page. City./Town State Zip Code Date of Inspection D. System Information 1 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for exampll 10 gpd x#of bedrooms): 440 Description: Number of current residents: UNKNOWN Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: — Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usa e d N/A 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts =,r? Title 5 Official Inspection Form ;1I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address --- -�--- ----- --- — _ -- CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name required for is y OSTERVILLE required for ever _ MA 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): -- — Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: r _ Last date of occupancy/use: --- .Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: n t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Fes`° Commonwealth of Massachusetts �,_--- Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE MA 02655 4/20/2021 required for every _ _�. _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.)' 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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: UNKNOWN Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 — feet C Material of construction; ❑ cast iron ® 40 PVC ❑ other(explain): — - Distance from private water supply well or suction line: 104 } feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �1-=- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is VILLE MA 02655 4/20/2021 OSTER _ required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1,feet Material of construction`. ® concrete ❑ meta! ❑ 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 GALLONS _ Sludge depth: - 31' Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 311 ---. _ Distance from top of scum to top of outlet tee or baffle . -- Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS ARE AT GRADE ON RISERS t5insp.doc•rev.712 612 011 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts . =(; Title 5 Official Inspection' Form ;� Jl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1_71 PINE LN UNIT 4 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name -- -- -- --- information is OSTERVILLE required for every _ MA_ 02655 _ 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top,of scum to top of outlet tee or baffle Distance from bottom of.scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: — gallons Design Flow: - ---. -- _ gallons per day t5insp.aoc•rev 7/2312018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts -_ �gP Title 5 Official Inspection Form I?' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < � 171 PINE LN UNIT 4 Property Address — CLOCKWORKS'II CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE required for every _ — MA _ 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.. 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: --- _ Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address - —_—— CLOCKWORKS II CONDOS ASSOCIATION _ Owner Owner's Name information is OSTERVILLE required for every OS _ MA_ 02655 _ 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: - -- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - t51nsp.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 — 1.! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE_L_N UNIT 4 Property Address — i ---- — CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE MA 02655 4/20/2021 required for every OSTERVILLE_________ _ _- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-PIT FOUND WITH V OF EFFLUENT DURING INSPECTION WITH NO EVIDENT STAINING. COVER IS AT GRADE 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.): l5insp.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 ul Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT_4 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name information is OSTERVILLE _ required for every _ MA 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): ' Materials of construction: -- Dimensions ----------- Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 k Commonwealth of Massachusetts Title 5 Official Inspection For 1,5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address ---- -- _ CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name- information -- equirefo is OSTERVILLE _ required for every MA 02655 4/20/2021 page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 5 nsp.doc•rev 7I26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts 1► ;. �w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 PINE LN UNIT 4 Property Address CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's Name -- — information is OSTERVILLE _ requiredd for every _. _ _ MA _ 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection l D. System Information (cont.) 15. 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: pate ❑ Observed site (abutting property/observation hole within 15.0 feet of SAS)' ® Checked with local Board of Health - explain: PRIOR REPORT ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: TEST HOLE DATA PER PLAN ON FILE AT BOH. REFERENCE PRIOR INSPECTION REPORT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t a Nye Commonwealth of Massachusetts �_— `P Title 5 Official Inspection For _._ In Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 171 PINE LN UNIT 4 _ Property Address -- ------ —_-- — CLOCKWORKS II CONDOS ASSOCIATION Owner Owner's er s Name information is OSTERVILLE required for every ._ _ MA_ 02655 4/20/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System information: For 8: T Ight/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 i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i i � 1 �"�, f� I' ��__6-�::x�� e1' ,,,, 1' �'�� n. �cF'` p „, ,� 1-�y� ��� ,tip � �� TOWN OF,BARNSTABLE LOCATION SEWAGE # 9 6 VILLAGE S T ASSESSOR'S MAP & LOT f ,? -.57 INSTALLER'S NAME & _PHONE NO. A & B C M 775-6264 s PTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF,BEDROOMS PRIVATE WELL OR PUBLIC WATER oeR.rs BUILDER OR OWNER e LoCk ti8oP/r( (`'o��a� � 3• DATE PERMIT ISSUED: 1•�0-5'S° DATE COMPLIANCE ISSUED: 4, VARIANCE GRANTED: Yes NO LP LO : O �J O � e O �J NO. / j Fee�o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plitation for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System YIndividual Components Location Address or Lot No. I r1 l P1ij6 4Av6 6S'rc-jL Owner's Name,Address,and Tel.No. Assessor's Map/Parcel !`? fJ 51&7 , D e?HA0 Installer's Name,Address,and Tel.No.j;g-471-8S77 Designer's/Name,Address,and Tel.No. GAVeW06 CijreAWAJ56 1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of fAilth. ned Date (c. Application Approved by Date (� " Application Disapproved by Date for the following reasons Permit No._ � 1 Date Issued In � s No. % r / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered ln computer. i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Disposal 6pstrm Construction Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Vindividual Components Location Address or Lot No. I tI l p(/JE LAiU6 OS-rdL Owner's Name,Address,and Tel.No. eTHw DiR."C-5 Assessor's Map/Parcel 117 O 51W l a a D kJ-?- 5T' Installer's Name,Address,and Tel.No. 5 -4Z7-8S?7 Designer's Name,Address,and Tel.No. GoAPeWt'DE 6WrUOVkJ56� (.LC,,D— V(Ar { ' Type of Building: Dwelling No.of Bedrooms Lot Size' sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ,r Description of Soil Nature of or Alterations(Answer when applicable) PERK n`R)OX R-an Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in t accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ne Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No.o Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 2--,/- BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by CA El I D&S C14- at 1P106_ (A U9 6-26 D) has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No..C t5 dated G / ej 1 5 Installer �PO Ct o� , Designer WA #bedrooms (�)'.�" Approved design flow gpd The issuance of thispermit shall not be construed as a guarantee that the system willlun ti rn as designed. Date �n I Inspector \\ ( - ------- ------------------------------------------------------------------------------------------------------------------------------ No. 1-5 "'"'_ J79-- Fee C THE COMMONWEALTH OF MASSACHUSETTS 71� C PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal &pstem Construction permit Permission is hereby granted to Construct( ) Repair(Xl) Upgrade( ) Abandon( ) System located at f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructs n (uss be completed within three years of the date of this permit! Date�� �(~\ '� Approved b Commonwealth of Massachusetts d�� a 0Q Title 5 Official Ins Form Inspection ,� p r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Win, 171 Pine Ln Unit 1 ;� Property Address Uri Clockworks II Condo Association /Larry Kirk ` Owner t Owner's Name information is required for Osterville Ma 02655 9-20-18 ' every page. City/Town State Zip Code Date of Inspection CAD 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: ti f I t Ins- ecor Information S /3�L/g When filling out A p _ �� forms on the computer,use Douglas A Brown only the tab key Name of Inspector to move your Douglas A Brown Inc cursor-do not Company Name use the return key. P.O Box 145 Company Address - Centerville Ma 02632 Citylrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1,have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-20-18 Inspe s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Fora (- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 ; every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary : Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At Time of inspection this system met all passing requirements. This report can not predict the future performance under the same or increased usage. This report is not to be used for bedroom count determination. 2) System Conditionally Passes: ❑ One or more system components.as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N, ❑ ND (Explain below): t5ins .doc-rev.7/26120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form f' I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M e 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk - - Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 'Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, ` safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: ; You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or Clogged SAS or cesspool El 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for 'Osteryille Ma 02655 9-20-18 every page. Cityrrown 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. . Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑` ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every 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 Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site?- ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Fora li; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 12 total Number of bedrooms(actual): 4 this unit DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 Description: This system according to as built and design plan consists of a 2500 gallon septic tank d-box and 2 leach pits All h-20 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 information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): n.a at time of report Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd)' Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 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 c Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 ' 9-20-18 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 i ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records,-if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: appear to be original to condo's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): R Distance from private water supply well or suction line: 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 , t Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association / Larry Kirk Owner Owner's Name information is required for Osteryille Ma 02655 9-20-18 every page. City/Town 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: 2500 gallon 12" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? previous insp 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.): Tank was functioning properly at time of this inspection. . s t5insp.doc•rev.7/26/2018-" Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Clsterville Ma 02655 9-20-18 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): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was level and functioning properly. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: 0 Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 . ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 'innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18' r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every 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.): Pits were opened and found to be functioning properly with a clear stain line at about 15 inches under the pipe invert. 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 f cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): " Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa a 15 of 18 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18' every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,ig Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,V 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner information is Owner's Name ' required for Osterville Ma 02655 9-20-18 every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) a 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: no g.w encountered at greater than 4 ft from bottom of s.a.s 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: design plan and previous inspection report from eco tech dated 10-10-14 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln Unit 1 Property Address Clockworks II Condo Association /Larry Kirk Owner Owner's Name information is required for Osterville Ma 02655 9-20-18 every page. Cityrrown 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 i 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 t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts P = T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments system: KGRNPI, ~ rror: 171 Pirn V,_,,Aaps ssor's Map 117 Block 58 Lot 20B-aka Clockwork 2 Condominiums,Uhit B Property Addre s opeiat+itivI N6mlfiee Trust,_Mary Josephine Meyl,Tr._ Owner Owners e — informationrl9bltIQn �� required for every Osterville MA. 02655 October 10,.2614 page. CltyRown State Zip Code Dale.or Inspection _. I E. Report Completeness Checklist 0 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 X[] Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOQICAL . PROFILE NOT TO SCALE i i t i i PRECAST O LEACH PIT o 2 O 80rroM Of LEA CHINO AEA DESIGN LEACHING IS PLAN ABOVE HIGH GROUNDWA TEA w o - NO . . GROUNDWATER ENCOUNTERED t5ns 3113 Title S 0146al Inspection Form:Slib$uHace Songe Disposal System•Page f 7 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Lane-Assessor'ssMap 117 Block 68..Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine He Tr. Owner Owner's Name Information is OStervii.le required for every MA 02655 October 10,2014 page. City/Town State Zip Code Oatr3 of Inspectlnn 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 El drawing attached separately • L -qF-SEPTIC C]6ECIMAFEET -DISTANCES IN 's EXIS. iNIG BUILDING rf ra2 22.� .� 3 q0 •UNIT 4 2 UNIT 9 UNIT 2 UNIT r • as ' NOT 1 TO '< 25t70 GALLON SCALE Q SEPTIC TANK PA VED DRIVEWAY t` 2` LEACH LEACH I PITPIT 3_ 00J3OX = i - VEOE TA TED AREA PINE LANE 508 364-0.894 tslns-3113 me 5 Offidei hspadion Form:Subsurface sewage bisposw system Page 15 of 17 r. un 2415 06:21 a p.1 �P /i± r1- ©58 -2-0P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works - Property Address Ethan Burnes Owner Owner's Name information is required for every Ostervitie MA 02656 6-23-16 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 and of the form. Important:When A. General information filling out forms ����7►�In++t++++/►q,� on the computer, ����� �tN OFMq ��i,, use only the tab 1. Inspector: �� s' key to move your cursor-do not James D.Sears .LAMES use the return Name of Inspector key CapewideEnterprises LLC * '' o o �I Company Name 5Z't''... .." , 153 Commercial Street �y'�ig,��n13NS��G�.�`� Company Address Mashpee MA 02649 City/Town State Zip Code 505-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-23-15 iQ'spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage oisposal System•page t of 17 Jun 2415 06:22a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name Information required for every Osterville MA 02655 6-23-15 page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank, D Box and pit B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", ".no"or"not determined' (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 0 Y ❑ N ❑ NO(Explain below): 15ins•3h3 Title 5 Official Inspection Forte:Subsurface Sewage Disposal System•Page 2 of 17 Jun 2415 06:22a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner owners Name information is required for every Ostervllle AAA 02655 6-23-15 page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): [] The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh (Sins-3/13 Title 5 Official Inspecdon form:80su(ace SmwNa Oisposa[System-Page 3 of 17 f Jun 2415 06:22a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln• Unit 4 Clock works Property Address Ethan Bumes Owner Owner's Name Information required for every Ost'erville MA 02655 6-23-15 page. City/Town State Zip Code Date of Inspedion 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 Tess 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 Q 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool esspool ❑ Liquid depth in is less than 6" below invert or available volume is less than Yz day flow P17T t5ins•3113 Title 5 Official Ins peditm Form;Subsurface Sewage Disposal System•Page 4 of 17 Jun 2415 06:23a p.5 Commonwealth of Massachusetts VTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name information is required for every Osterviffe MA 02655 6-23-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year XOT 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. ❑ 9 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 faits. 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. t5in3•3113 tlns 5 Of AI hspection Form Subsurface S swage Disposal System•Page 5 of 17 Jun 241506:23a p.6 Commonwealth of Massachusetts Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name information is required for every Osterville MA 02655 6-23-15 page. Cityf 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) }S ❑ Was the facility or dwelfing 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)1310 CMR 15.30215)j D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 ondoUnit Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Ming•3113 Title 5 Official htspedicn Form:Subsurface Sew%e Disposal System•Page 6 of 17 Jun 241506:23a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form ki 4�,vwi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name _ information is Ost�ervrll'e MA 02655 6-23-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank, D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2012-42,000Gals 2013-16,OOOGars Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date CommerciallIndustrial Flow Conditions: Type of Establishment: Design flow.(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personstsq.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: 45ins•3r13 Title 5 Official Ins ction Form:Subsurface pe Sewage Disposal System•Page T of 17 4 Jun 2415 06:24a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name information is Osterville MA 02655 6-23-15 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): s z General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system l ❑ 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): 15ins•,3113 110e 5 Official Inspection Form Subsulara Sweega Disposal System•Page a o`17 1 I f Jun 2415 06:24a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owners Name information is required for every OsteMlfe MA 02655 6-23-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1981 6-2015 New D Box Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 2'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.): Pipein is 4" PVC SCH 40. Septic Tank(locate on site plan): _ 1' Depth below grade: feet Material of construction: ® concrete ❑ metal' ❑fiberglass ❑ polyethylene 4 ❑ other(explain) If tank is metal,'list age: years .s age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast Sludge depth:' t5ins•3113 799 S Official Inspection Form:Subsurface�Wvaga Disposal Syslem•page 9 of 1T f Jun 2415 06:24a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name information is required for every Ostemlle MA 02655 6-23-15 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness _0 Distance from top of scum to top of outlet tee or baffle 12' Distance from bottom of scum to bottom of outlet tee or baffle 18' How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outletinvert,evidence of leakage,etc.), Tank at working level. Tank at 1'below grade w/both covers steel at grade in black top.lnlet tee,outlet baffle. No sign of leak age or over loading Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage D;spo9 at system-Page 10 o117 Jun 2415 06:25a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name information is required for every Osteryflle MA 02655 6-23-•15 page. Cityfrown State Zip Code Date zf 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 15ins-3113 Title 5 Official Irrspeclion Form Subsurface Sewage Disposal System•Page 11 of 17. Jun 2415 06:25a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owner's Name information is required for every osterviile MA 02655 6-23-15 page. Cityrrown State Zip Code Dale of Inspection D. System Information (cont.) Distribution Box(it 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 Wx 1T-29' Below grade wlsteel cover at grade in black top.One line out. Box is new 6-2015 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•3113 Tillie 5 Official Inapervion Form:Subsulms Sewage Disposal System•Page 12 of 17 Jun 2415 06:25a p.13 Commonwealth of Massachusetts Eff Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Bumes Owner Owner's Name information is Ost�erville requ ired for every MA 02655 6-23-15 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ? ❑ leaching trenches number, length- i ! ❑ 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 a 1000 Gal.Precast pit.w/4'stone. Pit is 28" below grade w/steel cover at grade in black told lot. Pit is dry w/stain line at 2' No sign of over loading i 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 15ins•3113 TO 5 Official trspectian Farts;Sutsurrace Sewage Disposal Syctam.Page 13 of 17 i t f Jun 2415 06:26a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form V , - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Bumes_ Owner owners Name information is required for every 0SieNtll2 MA 02655 6-23-15 page_ Cityfrown 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.): 1 t 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.): 1 t5ins•3113 Title 5 Official Inspealon Form Suosuriece 3@Wape U1SpoSel System•P;ws 14 of 17 j 1 Jun 2415 06:26a p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 171 Pine Ln. Unit 4 CIQck works Property Address - -- — --`v-- Ethan flumes Owner Owner's Name — rmation is QSheftfil� re wired for every MA 02655 6-23-15 page. Cityrrown state Zip Code Date of Insp ection 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 feet. Locate where public water supply enters the buifding. Check one of the boxes belovr ® hand-sketch in the area below L� drawing attached separatety j i I j r I 1 i i UNl � 0 c 1 . � 1 { t ----------- Gins•3/13 reJo 5 Micid ImpecVon Form:3bawlace i 4 SewaBe B�gvasa Sys!em•peg&75 of 17 Jun 241506:26a p.16 Commonwealth of Massachusetts - Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Ln. Unit 4 Clock works. Property Address Ethan Burnes Owner Owner's Name required a OSteryilfe MA 02655 6-23-15 required for every page. cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water s ❑ Check cellar i ❑ Shallow wells I Estimated depth tg iTig round water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system'design plans on record If checked, date of design plan reviewed: 10-2-81 Date D 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: I You must describe how you established the high ground water elevation: T.H.on Design plan 10-2-81. No G.W.at 12'. Bottom of pit at 8' below grade. Bottom of pit at 4' above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Dispose!System-Page 18 d 17 Jun 2415 06:27a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntar y Assessments 171 Pine Ln. Unit 4 Clock works Property Address Ethan Burnes Owner Owners Name information is QStIG'Nf��t3 required revery MA 02656 6-23-15 page. CiVrown 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 fife t t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system.Page 17 cf 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 171 Pine Lane -Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Hey[, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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, use only the tab 1. Inspector: f key to move your 4 cursor-do not David D. Coughanowr, IRSuse the return Name of Inspector key. Eco-Tech Rapid Response Company Name 155 George Ryder Road South Company Address Chatham MA , 02633 City/Town State r` Zip Code 508 364-0894 1328 - Telephone Number License Number f 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 OF El❑ Conditionally Passes ❑ Fails �o�� DAVIq ❑ Needs Fu tie Evalt,ptl Local Approving Authority OUGHANOWft No.132$ f Rov�o o� October 40, 20.14, Inspector's Signatur M INSP� 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 f[ow•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. f 1 (Sins•3/13 Title 5 Official Inspection Fonn: s rface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville . MA 02655 October 10, 2014 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is recommended. 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�thesepticta�nky(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrationRorjpft-,fatl.urgs imminent. System will pass inspection if the existing tank is replaced with a�eoniplying;septic,tan,k as approved by the Board of Health. t� i+°�r^i�t>I; sa�t<,) *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 20jyears oltl is allable. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 h Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is Osterville MA 02655 October 10 2014 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) ❑ 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 I 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): f 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 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh e t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2•Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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 1/z day flow t5ins•3113 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:. . . 5 M 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 page. City/Town State Zip Code Date of Inspection B. Certification'(cont.) Yes No A a ❑ ® 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 ❑ 0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public'water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section'D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate, regional office of the Department. t5ins•3/13 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 171 Pine Lane -Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2".Condominiums Unit B Property Address Heyl Nominee Trust Mary Josephine Heyl, Tr. Owner Owner's Name information is Osterville MA 02655 October 10, 2014 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 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. e ® a 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): 12 (bld Number of bedrooms (actual): 4 (this unit) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 5 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: A 12 bedroom system shared by 3 condo units was installed by J.P. Morin in 1984.Assessor's records show 4 bedrooms in this unit.. Number of current residents: 0 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection a 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)): 49 gpd Detail ` 2012: 21,000 gallons 2013: 15,000 gallons ; Sump pump? ❑ Yes ® No Last date of occupancy:- . not determined 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.): , • iq 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 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 171 Pine Lane -Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? I Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 171 Pine Lane-Assessor's Map 117 Block 58 Lot 2013-aka Clockwork 2 Condominiums Unit B Property Address - Heyl Nominee Trust, Mary Josephine Heyl Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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: 30+ years. Disposal Works Permit for new system was issued 5/31/1984 (Permit#84-470) Were sewage odors detected when arriving at the site? ❑ .Yes ® No Building Sewer(locate on site plan):', q Depth below grade: - 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): i Distance from private water supply well or suction•line: feet r Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leaka e'or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 9 • If tank is metal, list age: years „ Is age•confirmed by a Certificate of'Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: , 13 x 7 x 6-2500 gallon Sludge depth: 14 in t5ins•3/1 3 k 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 a' 171 Pine Larie -Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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 20 in Scum thickness 4 in Distance from top of scum to,top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle. 12 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Tank is H-20. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' ^M 171 Pine Lane -Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. T r Owner Owner's Name information is required for every Osterville MA 02655 October 10 2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 4 � Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑.,Yes ❑ No , Alarm level: Alarm.in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): • {. *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Pine Lane -Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Camera inspection showed no adverse conditions 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of,Massachusetts f W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 171 Pine Lane -Assessor's Map 111 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name ' information is required for every Osterville MA 02655 October 10 2014' page. City/Town State- Zip Code Date of Inspection - D. System Information (cont.) Type ® leaching pits number:' 2 ❑ leaching chambers r ' number: ❑ leaching galleries. b 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.): Soils above leaching system appear unsaturated. No evidence of surface ponding, breakout, lush ' vegetation, or other evidence of hydraulic failure was observed. One leach pit was opened and contained 30 inches of effluent. Unit is H-20. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer - Depth of scum layer ; Dimensions of cesspool Materials of construction = Indication of groundwater inflow ❑ Yes ' ❑ No t5ins-3/13 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System-Page 13 of'17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e wM 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Comments (note condition of soil,,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form m e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Pine Lane-Assessor's Map 117 Block 58 Lot 20B -aka Clockwork 2.Cond'ominiums Unit B Property Address Heyl Nominee.Trust,_Mary Josephine Heyl, Tr. Owner. Owner's Name information is required for every Osterville MA . 02655 October 10; 2014 page. Cltyrrown State Zip Code . -. Date-of Inspection . D. System Information (cont) Sketch Of Sewage Disposal System:Provide.a view of the sewage disposa:B 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 L O C A.TIONS ; —OF SEPTIC COMPONENTS -DISTANCES IN DECIMAL FEET A B EXIS T§N.G 1. 13 17 BUILDING 2 _ 22.¢, 26 3 40 36.5. UNI T� � 'UNIT 3 UNIT 2 UNIT 1' ' � B _ A ' NOT ' 2S00 GALLON,. SCE O SEPTIC TANK PA VIED DRI VEWA Y 2 LEACH .PIT LEACH.. . ' PIT D—BOX VEGETATED AREA q . PME L.A NE. 5 364-0894 08 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 171 Pine Lane-Assessor's Map 117 Block�58 Lot 20B -aka Clockwork 2 Condominiums Unit B Property Address Heyl Nominee Trust, Mary Josephine Heyl, Tr. Owner Owner's Name information is required for every Osterville MA 02655 October 10, 2014 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: 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. 5/31/1984 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: Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the bottom of a witnessed test pit in which no water was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts P = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments system: KERNEL 'r c� 171 Pi Ap sessor's Map 117 Block 58 Lot 20B -:aka Clockwork 2 Condominiums Unit B M rror: '�"a� Property Address operat¢17ayl NdPrMee Trust; Mary Josephine Heyl jr. Owner Owner's2be . informationF qs ition required for every Osterville MA 02655 October'10,2014 ` 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 .F . GEOHYDROLOGICAL PROFILE : - NOT TO SCALE I PRECAST Z .LEACH PIT O BOTTOM OF LEACHING �- ... PER DESIGN - PLAN LEACHING IS ABOVE HIGH. GROUNDWATER 41 . . . - NO r44 GROUNDWATER ENCOUNTERED t5ins-3113 . w Title 5 Official Inspection Form:Subsurface Sewage-Disposal System•:Page 17 of 17: