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HomeMy WebLinkAbout0210 PINE LANE EXTENSION - Health n 11-7 _ 0 0 o � i Qsterville P (,St�f V; I Ie �0 YY�1Y6C(►.S' ?F . A = 117 075 DI Ik Commonwealth of Massachusetts { �n 1p . Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 210-216 Pine Lane Ext. } u Property Address ^' i0 Osterville Commons Owner Owner's Name information is Osterville MA 02655> 10-28-20 required for every page. Y Cit /Town State Zip Code Date of Inspection a -. 9 - Inspection results must be submitted on this form. Inspection forms may.not be altered in any way. Please see completeness checklist at the end of the form. OF uq * Important:out forms A. Inspector Information �/0. a 0 . filling out forms =-N. JAMES on the computer, _ use only the tab Janes D Sears =o SEARS key to move your Name of Inspector cursor-do not Robert B.Our Co. INC key the return Company Name F S IN Sp�Gp��`���` Y 363 Whites Path 11110���� Company Address South Yarmouth MA 02664 City/Town State Zip Code' . ienun 508-477-8877 S 1623 Telephone Number License Number B. Certification 1 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. ❑ Faits 10-29-20 pector's Signature Date The system inspector shall submit a copy of this inspection report to the ApprovingAuthority (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 ofthe DEP. The original form should besent 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 Title 5 Official Inspection Form II Subsurface Sewage Disposal System form -Not for Voluntary Assessments 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every page. CitylTown 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:^ ® n I have not found any information which indicates that any of the failure crite ria 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 two 1500 Gal Tanks- D Box and 18 Chamber's. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass section need to be r 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 ifit is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is Tess than 20 years old is available. Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every 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):.:- El 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•MPage 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.). ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is.within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary,to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 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 �I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 210-216 Pine Lane Ext. u� Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every page. City/Town State Zip Code Date of In 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 ❑ N. Liquid depth in is less than 6" below invert or available volume is less than '/z day flow o�F,011,11'e El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number'oftimes pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply'or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® 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 20.00 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 r Commonwealth of Massachusetts w Title 5 Official -Inspection Form Subsurface Sewage Disposal System form =Not for Voluntary Assessments 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20` required for every page. City/Town State Zip,Code Date of Inspection C. Inspection Summary (cont:) ; If you have answered "yes" to any,question-in Section C.5 the system is considered a significant threat, or answered "yes"to any question iri 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 a//inspections: Yes No ®. ❑- P.u_mping information.was provided by the owner, occupant, or Board of Health ❑ Z 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 0 ® k 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. El ® '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)] 0. 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 r �i; Subsurface Sewage Disposal System form -,Not for Voluntary Assessments 210-216 Pine Lane Ext.- Property Address Osterville Commons Owner Owner's Name information is Osterville 'MA 02655 10-28-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): . 12 Number of bedrooms(actual): 12 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 Description: - 2-1500 Gal.flank's D Box and 18 chamber's. NA Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes -0 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 NA Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of'18 Commonwealth of Massachusetts Ip Title 5 Official inspection Form yI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210-216 Pine Lane Ext. u' Property Address Osterville Commons Owner Owner's Name information is MIA. 02655 10-28-20 required for every Osterville page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: (based on 310 CMR 15.203 Design flow_(ba ) Gallons er da a 9 ` P Y(9P ) Basis of design flow(seats/persons/sq.ft.,`etc.): Grease trap present? ❑ Yes ❑ No Water treatmentunit.present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to theTitle,5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: 6-20-20 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 Commonwealth of Massachusetts P Title 5 Official Inspection Form q - I0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " !% 210-216 Pine Lane Ext. v Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.). 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ 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: na Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 38, Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40 I _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210-216 Pine Lane Ext. v Property Address Osterville Commons Owner Owner's Name information is required for every Osteryille MA 02655:, 10-28-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): # 1 # 2 Depth below grade: 28 3' Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 1500 2 1 Sludge depth: Distance from,top of sludge to bottom of outlet tee or baffle 28" 29" Scum thickness 8,0 8„ Distance from top of scum to top of outlet tee or baffle 16" 18" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Asbuilt Jape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tanks at working level. Front tank and outlet cover at 28". W/inlet cover at 5". Two inlet tee's out let tee.Rear tank at 3' below grade. Inlet cover 18"cement at grade.W/outlet cover at 16". In and outlet tee's No sign in tank's of leakage or over loading t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I; V � 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 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 Ell fiberglass ❑.polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ' ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form r M1I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210-216. Pine Lane.Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 State Zi Code Date of Inspection page. Y Cit /Town P D. System Information"(cont.) 8. Tight or Holding Tank(cont.) \. Alarm present: ❑ Yes ❑ No, working order: Yes No Alarm in wo ❑ Alarm level: 9 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.): D Boxis 44" below grade Box is clean and solid w/no sign of over loading or solid carry.over. t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachuse#ts i- Title 5 Official Inspection- Form �I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210-216 Pine Lane Ext. Property Address Osteryllle Commons Owner Owner's Name " information is Osteryille MA 02655 10-28-20 required for every page. Cityfrown 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: ® leaching chambers number: 18 ❑ 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 f • c Commonwealth of Massachusetts Title 5 Official Inspection" Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osteryille MA 02655 10-28-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of .vegetation, etc.): Leaching is 18 chambers at 41' below grade. Chamber's are wet'on bottom. No sign of over loading 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.): I Disposal S 1 t5insP.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage 9 P osal System•Page a 14 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 210-216 Pine Lane Ext. T Property Address Osterville Commons - Owner Owner's Name _ information is Osterville MA 02655 10-28-20 required for every _ page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) p. 13. Privy(locate on site plan): 5. . 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 - Fig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210-216 Pine Lane Ext. u Prope.rty Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: ties t o at least two perma nent reference dis osal system, includingp Provide a view of the sewage p _ y landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C. � a 57 C-6 / L 0 0 3• xe- 9v �_� ^G 3• 3 0 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form Not for Voluntary Assessments : 210-216 Pine Lane Ext. Property Address Osterville Commons Owner Owner's Name information is required for every Osterville MA 02655 10-28-20 page. City/Town State _5 Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /✓v 12'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the,high"ground water elevation: ® Obtained from system design plans on record 12-12-95 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: T H on Design plan 12-12-95 12' no G.K. 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 l'nspection Form !- A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210-216 Pine Lane Ext. u Property Address Osterville Commons Owner Owner's Name information is Osterville MA 02655 10-28-20 ; required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist o 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 compieted'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 DisposalSystem drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included /•A 1 ' I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 18 of 18 Dec 16 2018 23:43 HP Fax page 22 Commonwealth of Massachusetts �` 0�5 " D0-A Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �x{t CP 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name ' information is Osterville � MA 02655 12-12-18 � required for every State Zip Code Date of Inspection page, Cityrrown 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. UNW%w I uuOF rq��/�i Important:When A Inspector Information / / �� ��'� �' °9�y r 15 .filling out fors r5 3 a O: G on the computer, 5 JAMES rt, use only the tab James D.Sears key to move your Name of Inspector p ap Cewide Enterprises cursor-do not � �•. c� O r s use the return Company Name �''�,, 4. .... t••"EG��p�`� key. 'yip, S INS? 153 Commercial Street Company Address Mashpee MA 02649 Cityrrown State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification I certify that:I am a DEP approved system inspector In full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems,After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails as,1 L44- S9'A4:n4 r 12-12-18 I actor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. r ' 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. t5lnsp.doc•rev.7/2612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 1 of 18 Dec 16 2018 23:44 HP Fax page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210 +216 Pine Lane Ext, Property Address Osterville Commons First Property Management Owner Owner's Name required Information Is Osterville MA 02655 12-12-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system Is two 1500 Gal Tanks D Box and 1 B chambers. 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): Wrnp.doc-rev.7/26=18 7tle 5 Oftal Inspection Form Subsurface Sewage NspasW Systern•Page 2 0118 Dec 16 2018 23:44 HP Fax page 24 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Osteryille MA 02655 12-12-18 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 ❑ NO(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.7126/201 B Tills 5 Metal Inspection rorm:Subsurtece Sewage Disposal System•Page 3 or 18 Dec 16 2018 23:44 HP Fax page 25 c Commonwealth of Massachusetts RWj Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Osterville MA 02655 12-12-18 page. Cityrrown Stale Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: *• This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp doc-rev.7l26120i8 Titia 5 Official Inspection Form:Subsurfaoe Sewage Disposal System-Page 4 of 18 f Dec 16 2018 23:44 HP Fax page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vdr 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name Information is Osterville MA 02655 12-12-18 required for every State Zip Code Date of Inspection Page. CitylTown 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 u is less than 6" below invert or available volume is less than'/z day flow/-EAOfm El ® 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 collform 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 fills.I have determined that one or more of the above failure El ® 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 151nsp.coc•rev.712612018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Dec 16 2018 23:45 HP Fax page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210+ 216 Pine Lane Ext. u Property Address Osterville Commons First Property Management Owner Owner's Name information is Osterville MA 02655 12-12-18 required for every page. CitytTown state Zip Code Date of Inspection C. Inspection Summary (cunt.) 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: i Yes No ® ❑ Pumping information was provided by the owner, occupant; or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? . ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® Cl Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ` ❑ 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.7/25/2010 Title 5 Official Inspection Forn+:SUbsuface Sewage Oisposel System•Paae 6 of 16 Dec 16 2018 23:45 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is required for every Osterville MA 02655 12-12-18 page. CitylTown 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: Two 1500 Gallon Tank D Box and 18 Drywells Number of current residents: 0 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 years usage(gpd)): 2016-104,000Gal Detail: 2017-98,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc•fey.7/20/2018 Title 5 Ofti ial inspection Form:SubsuAace Sewage Disposal System•Page 7 of 16 Dec 16 2018 23:45 HP Fax page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name Infamliatlon Is required for every Osterville MA 02655 12-12-18 require page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design Flow(seats/persons/sci t.,etc.): Grease trap present? ❑ Yes ❑ No 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: Pumping every 2 years. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doa•rev.712MI111 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Pege 8 of 18 f Dec 16 2018 23:46 HP Fax page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Osterville MA 02655 12-12-18 page, Cityrrown State Zp 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5, Building Sewer (locate on site plan): Depth below grade: 42" 3' 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.): Ping is 4" PVC SCH 40. t5inap.doc-rev.7126/2016 Title 5 official Inspection Fwm:Subsurface Sewage Disposal System•Page 9 of 18 Dec 16 2018 23:46 HP Fax page 31 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 210 + 216 Pine Lane Ext, Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Osterville MA 02655 12-12-18 page, City/Tom State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3' 28" 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: 2/1500 Gallon Sludge depth: 2 2„ Distance from top of sludge to bottom of outlet tee or baffle 28 28 Scum thickness 1" 1" Distance from top of scum to top of outlet tee or baffle 81- e„ Distance from bottom of scum to bottom of outlet tee or baffle 17" 17" ' How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both tanks at working level Win let cover at 4", in and outlet tees. No sign of leakage or over loading. tSinsp.doc•rev.7/26/ZD18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 1B Dec 16 2018 23:46 HP Fax page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form ., Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information Is required for every Osterviile MA 02655 12-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 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.): B. 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 15inap.doc-rev.7128/2018 TIO--5 Oflidal Inspection Form*Subsurface Sewage Disposal System Page 11 of 18 Dec 16 2018 23:47 HP Fax page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is Osterville MA 02655 12-12-18 required for every page. CitylTown 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 No Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc,): D Box is clean and solid. Box and cover at 47"w/6 line's out. No sign of over loading or solid carry over. t5inspAoc•rev.7/2612018 Till-5 official Inspeaw Form:Subsurface Sewage Disposal System•Page 12 of 18 Dec 16 2018 23:47 HP Fax page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Osterville MA 02655 12-12-18 page, Cityrrown State Zip Code Date of Inspection D. System Information (cons) 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: ® leaching chambers number: 18 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: tFinspAm•rev.712612018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18 Dec 16 2018 23:47 HP Fax page 35 Commonwealth of Massachusetts Title 5 official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Osterville MA 02655 12-12-18 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Solt Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching is 18 500 Gal. well chamber's. Leaching is clean and dry. No sign of over loading or solid carry over. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer . Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26=18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Dec 16 2018 23:47 HP Fax page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is OStefVllle required for every MA 02655 12-12-18 we. 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.): t5in .doc•rev.W26 1 . � � 8 Title 5 Official Ins Ilion Form;Subsurface a Pe ce Sewage D'isposal System•Page 16 of 18. Dec 16 2018 23:47 HP Fax page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name Information is required for every Ostenrille MA 02655 12-12-18 page, CitylTovm 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 l5insp.doc-rev.7/26/2018 'rite 5 Of ial Inspection Farr:Subsurface Sewage Dlsposal System•Page 16 of 1b Dec 16 2018 23:47 HP Fax page 38 Map r c Page l of 2 Town of Barnstable Geographic information System Parcel Viewer Custom Map Abutters Map Size . Zoom Out 111111 1 1,In 1 � a , J 1 ♦ 1 , i ♦ 1 I "1 I ♦ r 1 � � I• .' fJiV I� y t ,:.. 6 w G � c 4 `• 6 o Q o l ;_..............-_---., ........._..._..._._._........__—.......... .._._._: - Set Scale 1" _!20 1 I Aerial Photos I MAP DISCLAIMER r ,.inter)nnA.,)nno TA-m nI Rernefohlo Ua AN Anhfe meenn l�tf,.•1/�snsmr Mttrt� horr�c4al�la 'n� rJo/arnimelonrtnPnann/mar atrtv7nrnrtAf•ItrTTl=1 1'1n'151)1 AR, em;mnno Dec 16 2018 23:48 HP Fax page 39 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons First Property Management owner Owner's Name information is Osterville required for every MA 02655 12-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ .Check cellar ❑ Shallow wells N° Estimated depth to tiigh 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: 12-12-95 Date ❑ Observed site(abutting propertylobservation 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: T.H, on design plan 12-12-95. No water at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6insp.doc•rev.712612018 Title 5 Off bal Inspection Form:Suhsurface Sewage Disposal System-Page 17 of 18 Dec 16 2018 23:48 HP Fax page 40 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is required for every Osteryille MA 02655 12-12-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this forth inclusive of: ® A. Inspector Information:Complete all fields in this section ® B.Certification:Signed & Dated and 1, 2, 3, or 4 checked ® C. inspection Summary, 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information, For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included b' CNAM(3£Rs b� �•v G, w t5lnsp.doc-rev.7126/2018 Title 5 of ial Inspection Form:Subsurfaoe Sewage Disposal system•Page t6 of 16 v 11 2015 23:10 Jim The Inspector Man 5085349019 page 1 D75//7- - Commonwealth of Massachusetts Z . Title 5 Official Inspection�Form of _ s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name Information is Ostrville MA 02655 11-10-15 required for every , page. City/Town State Zip Code Date of Inspection 01 Inspection results must be submitted on this form. Inspection forms may not'be altered in any way. Please see completeness checklist at the end'ofthe form. Important:When filling out forms A. General Information \"pHnunn�pq on the computer, / ���`` jl{OFly �q /1' use onlythe tab .�� ��.•• `rS '�i� 1. Inspector. •'•9�,', key to move your y cursor-do not �O'•• James D.Sears _ JAME Suse m key.the return Name of Inspector co E Capewide Enterprises,.LLC * ' Q Company Name s' l • 153 Commercial Street ���''��;� s i N s C�°°�� Company Address _Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I 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 -11-10-115 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. ,gyp l/S t5i ns 3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every astrville MA 02656 11-10-15 page. City[Town State Zlp Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,S,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 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is two 1500 Gal. Tanks D Box and 18 chambers 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. i 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): thins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is required for every Ostrville MA 02655 11-10-15 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes.(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N _❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ .Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to'broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 - Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page_3 of 17 Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts V IMP Title 5.-Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 210 +216 Pine Lane.Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Ostrville MA 02655 11-10-15 .page. CilyrTown 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 coiiform 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 t ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in appopM is less than 6" below invert or available volume is less than 1/2 day flow £A�iYia G t5lns•3/13 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 4 of 17 . Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Ostrville MA 02655 11-10-15 Page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality.analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- I0,000gpd. ❑ ® The system JkLs.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 ❑ . 0 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 consideredfa 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 1.5.304. The system owner should contact the appropriate regional office of the Department. t5uie•3J13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rf 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property.Management Owner Owner's Name informationis required wir for for every Ostrvllle MA 02655 11-10-15 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant;or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Ej 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? ® 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 12 Number of,bedrooms(actual): 12 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 1320 [Sins•3/13 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Information is Owner s Name required for every Ostrville MA 02655 11-10-15 page. Cltyrrown State Zip Code Date of Inspection D. System Information Description: The system is two 1500 gallon tanks, b Box and 18 drywells 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 Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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/sci t., etc.): Grease trap present? "❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t51ns•3M 3 - Title 5 Official Inspection Form.Subsurface Sewage'Disposal System•Page 7 of 17 , Nov 11 2015 23:10 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Ostrville MA 02655 ' 11-10-15 page. City(rown 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: Pumping every 2 years. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the 1/A system by system operator under contract 1 ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins 3/13 Tilts 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 8 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page .9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information Is required for every Ostrville MA 02655 11-10-15 page. Citylrown Slate Zip Code Date or Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): - . Depth below grade: 42" 3'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.): peing is 4" PVC SCH 40. Septic Tank (locate on site plan): Depth below grade: 3' 2 t3"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: 2/ 1500 Gallon Sludge depth: 2' :3" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage blsposal System-Page 9 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 210 +216 Pine Lane Ext Property Address Osterville Commons First Property Management Owner Owner's Name information is Ostrville MA 02655 11=10,15 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 27 Scum thickness 1 ' 1 Distance from top of scum to top of outlet tee or baffle 8 ti ' Distance from bottom of scum to bottom of outlet tee or baffle 17" 17" How were dimensions determined? Asbuilt -Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both tanks at working level w/inlet cover at 4",in and outlet tee's. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Dace 15ins 3l1° Title 5Official lnspectlon Form:Subsurface Sewage Disposal System•Page 10 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 +.216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owner's Name information is required for every Ostrville MA 02655 11-10-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ oth.er(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 Tltla 5 Official Inspeclion Fonn:Subsurface Sewage Disposal Systerr•Pape 11 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 210 +216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is required for every Ostrville MA 02655 11-10-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is clean and solid, Box and cover at 47" below grade w/6 line's out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System (SAS) (locate on site.plan, excavation not required)`. If SAS not located„explain why; t5ins•3/13 Title 5Official Inspection Form:Subsurface Sewage Disposal Systerr•Page 12 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 210+ 216 Pine Lane Ext. Property Address Osterville Commons First Property Management . Owner Owner's Name information is required for every Ostrville MA 02655 11-10-15 . page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 18 ❑ leaching galleries. number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeialternative system Typetname of technology. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is 18 500 Gal. Dry well chambers. Leaching is clean and dry. No sign of over loading or solid carry over. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool, Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t51ns-3112 Title 6 Official Inspection Form:Subsurface Sewage Disposal.System•page 13 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210+216 Pine Lane Ext. Property Address Osterville Commons First Property.Management Owner Owner's Name information is required for every Ostrville MA 02655 11-10-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of.soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3WU Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•3 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is required for every Ostrville MA 02655 11-10-1 5 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Nov 11 2015 23:11 Jim The Inspector Man 5085349919 page 16 © Sr V 0? Nov 11 2015 23:12 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts -• Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner Owners Name information is required for every Ostrville MA 02655 11-10-15 page. CityrFown Stale Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells D N Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record ' If checked, date of design plan reviewed: 12-12-95 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:. T.H.on design plan 12-12-95. No water at 12' Before filing this Inspection Report , see Report Completeness Checklist on next page. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Nov 11 2015 23:12 Jim The Inspector .Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 210 + 216 Pine Lane Ext. Property Address Osterville Commons First Property Management Owner owners Name information is required for every Ostrville MA 02655 11-10-15 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater_ ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 Bk 23677 PS 162 DEED RESTRICTION k0m 14ee /(U.5 l n WHEREAS, a`l e lJe c�Ct !V l�i�ga rrY � r!/S�Pe y � lyc( (ea- 06 17 e A of Newha nQ M-A Is the owner of the land with the buildings thereon I cated_a&fi J T lore A fin_ inn C W vlllfl, Ba rig 61CJ) le Co niv MA(hereinafter referred to as And beingshown on a plan entitled"au�.a;..:-=�^ �T anal;n /��. �/ P l� WrJl�I)�l9if'l!!,Crk'J CTw-><ec/ 6. /(09fer Deeodit+ed M4y a, 1,7, recorded wj4i )sC,_rnS _ + tt c'_ectnf- fgrs y �C- DeedStn3ooK ►V731 ✓'� ic!C' . Q01f-Ned � .ni< 1Ib99 pc; � 111) aY e;v d J L �n�l�lnl rPrn $g pgb rty RegiStl o_LDeed1s in Plan Rook pggg WHEREAS, P ,ca 1 rn)qo r ✓' Q -e ,as the owner of said lot has agreed With the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code,Title V,Minimum Requirements-for the Subsurface Disposal of Sanitary Sewage; e � , WHEREAS,the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works., construction permit for a septic system in compliance with 310 CMR 15.200,State Environmental Code, Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage,and authorizing the issuance of a building permit for the construction of a single family home on this property,is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, .11 NOW,THEREFORE,Oe CC aY Cb 1 l U 1 Q'e— ;does hereby place the following restriction on ki&above-referenced landAn accordance with big:agreement with the Town of Barnstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: �U r /'/de kan e f"Xlr 0S1e r y1'1f � � 1� may have constructed`upon The lot a house containing no more thanh'�Qe (3) bedroomsQQCL0. G.(n a rd ru 1-e Q ,agrees that this shall be permanent deed restriction affecting Located an , fe hyt �{, MA and being_shown on the plan recorded in Plan Book rl 539, ;Page. Or on Land Court Plan For title,see the following deed in Book �� ,Page�Or Land Court Certificate of Title Executed as a sealed instrument this. 0 day of M ,2009. Owner's Signature 12600 f Owner's Signature COMMONWEALTH.OF MASSACHUSETTS BARNSTABLE, SS 2009. Then personally appeared the above named t L V CGS 1J. L G Pq known to me to be the person(s)who executed the Foregoing instrument and acknowledged the same to be ji G free.act and deed,before me, Notary Public; My commission expires: co jZZ co S J 88a � 3 c. 8t3 0 4;. o ,4 -54,vny p z � 3 A /� v /sic y /o ��--� t7d� rE ST.13` Gl/C GG�j',�2c0 - .PC�E/ ,B,G'�-�T.�.i+7-` / G.._.s � �p/Zs�� � !� /" � LO•A•.� .I� l0 q 4,y [J ,,SA.d4 ZYv y / Jo 2 s WCO=0 v � C z ,zfFG%�u �1 Gvf�TE U, . C�'� 0. 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N Lol vo y k4 100, 3. f O g TE DESIGN: Ao DRAWN: K/ \1,151 CHECK: FILE#:3 c� J •�Z DWNG#: j--- (3 u►I Z►nl a TOWN OF BARNSTABLE LOCATION a a+ at:(o t ►^I !//a^'1.. SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ' 1 S R GPI LEACHING FACILITY: (type) (size) C-A4^�cr6 NO.OF BEDROOMS r BUILDER OR OWNER QS-rtry►�� C 041 n RAI PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply..Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(Iff any.wetlands exist within 300 feet of leac ing facility) .. Feet Furnished by J � aro Ap 07 O 3t