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HomeMy WebLinkAbout0039 TOWER HILL ROAD UNIT BLDG 1 UNIT 1B - Health (3) '7-- I va -a TOW �( 39 TOWER HILL ROAD—Village Square Ostervi Ile North iA .......................................................-........................................................................_.................................................................................................. ........_............................................. Parcel(no dashes) Street no Street Village Owner name -- _._,.._ More Search Fields 39 Tower Hill Road Osterville ............. ........................ ......... ............ Reset A i Parcels Total Pages:6 Rows/Page:.10 Developer Sewer Parcel location Village Owner lot Account Index Map 117-072-OOA 39 TOWER HILL ROAD,BLDG 1 Osterville BATES,EARL S&MCDONOUGH,MARY B TRS No 1729 11707200A 0 UNIT lA _... ............. 117-072-OOB 39 TOWER HILL ROAD,BLDG 1 Osterville FISHER,M LYNN TR No 1729 117072006.0 UNIT 1B .......... _..__......_.. ..... . _............. . ........... _ ............ . ............. ..... .-.. _..... ........... .._._........ ....... .................- 117.-072.-OOC, 39 TOWER HILL ROAD,BLDG 1 Osterville GILLIS,GARY C&MARY L No 1729 UNIT 1C 117-072-OOD 39 TOWER HILL ROAD,BLDG 1 Osterville KNAUS,GRETCHEN No 1729 11707200D 0' UNIT 1D .......... ... 117-072_OOE 39 TOWER HILL ROAD,BLDG 1 Osterville CANUSO,SAUNIE TR No 1729 17p7?OOf:_0 UNIT 2A __ .......... ,.._,..............._ ...-_......_ _...... .. ..._.... 117-072-OOF 39 TOWER HILL ROAD,BLDG 1 Osterville LAVALLEE,CAROLE H No 1729 117072QQEQ UNIT 2B 117-072-OOG 39 TOWER HILL ROAD,BLDG 1 Osterville RYAN,THOMAS F 1R&KATHERINE E No 1729 :170?200G UNIT 2C _._........ ....... ....._ _. . .......... . .__... .......... ..... . ......................................._ ................... .......... 117-072-OOH 39 TOWER HILL ROAD,BLDG 1 Osterville MCCOOLE,JANET No 1729 11Z{)7200110 I UNIT 2D 117-072-00I 39 TOWER HILL ROAD,BLDG 2 Osterville HUNGERFORD,MARYANN C No 1729 /170720010 UNIT 4A 117-072-OOJ 39 TOWER HILL ROAD,BLDG 2 Osterville PLUNKETT,LINDA J TR No 1729 1:1.?(}7200.10 UNIT 4B Map Parcel does not exist 2019-Town of Barnstable-Health Master TOWER HILL.ROAD,Osterville-OFF MAIN ST TO POND STREET - Y • 1/1 ................................................................_.................................................................................................................................. ....................... ..................................................................._........................._..................................................................................._................................_..._......................... .._.. Parcel(no dashes) Street no Street Village Owner name ------------- Sf r More Search Fields ..... 39 Tower Hill Road Osterville .... ......... Reset Parcels Total Pages:6 Rows/Page:r10 Developer Sewer Parcel Location Village Owner lot Account Index Map 117-072-OOK 39 TOWER HILL ROAD,BLDG 2 Osterville BIANCHI,WALTER E&MARJORIE H No 1729 11707200K UNIT 4C ........ ........._... 117-072-OOL 39 TOWER HILL ROAD,BLDG 2 Osterville MCGILLEN,DOROTHY R&JAMES F No 1729 11707200L 0 UNIT 4D .. .........................._..... ._.. ............ _,, ..... 117.-072.-OOM. 39 TOWER HILL ROAD,BLDG 2 Osterville MACALLISTER,ROBERT D&LINDA A No 1729 117U71QQM„® UNIT 5A 117-072-OON 39 TOWER HILL ROAD,BLDG 2 Osterville MCDOWELL,KIMBERLY W µ No w 1729 11707200N UNIT 5B ......... .. ....... .._.................. 117.Q72-QQQ 39 TOWER HILL ROAD,BLDG 2 Osterville BAKER,BENJAMIN B&DEBORAH A No 1729 7:17.Q7?OQ Q UNIT 5C . _. _.._ 117-072-OOP 39 TOWER HILL ROAD,BLDG 2 Osterville SNYDER,RICHARD 1 TR No 1729 11707200P 0 UNIT 5D 117-072-OOQ 39 TOWER HILL ROAD,BLDG 2 Osterville MULLIN,MARY&LOUGH,FREDERICK No 1729 117077.00Q UNIT 3 ... ................ 11.7-072-OOR 39 TOWER HILL ROAD,BLDG 3 Osterville KARAMANOS,TERESA S TR No 1729 1170720OR _._ UNIT 6 117-072-OOS 39 TOWER HILL ROAD,BLDG 3 Osterville FREEMAN,HOPE No 1729 11707200E 0 I UNIT 7 _.._.. __.._._._.. .. ..... __.._... _ _ ..... ........... . . .............. 117-072-00T 39 TOWER HILL ROAD,BLDG 3 Osterville ROSS,DIANE F No 1729 .1.1.70720OT Q UNIT 8 •Map Parcel does not exist 7 2019-Town of Barnstable-Health Master TOWER HILL ROAD,Osterville-OFF MAIN ST TO POND STREET 1l1 i ............. . .. ............. . .. Parcel(no dashes) Street no Street Village Owner name More Search Fields _.- _.__. _ _. ..__.. _.... .._._ ..w 39 .....£ Tower Hill Road Osterville + E ................. ............................... .._........-. ..._._..._._._ .. Reset Parcels Total Pages:6 Rows/Page:110 ° __.M......_._........... Developer Sewer Parcel Location Village Owner Lot Account Index Map _.. __ _.....,._,..__ .. _. ...... _ ._...... __. ,._. ...... _.. _,,. _ . ..._.. .._. _.. _..._ ._..... 117-072-OOU 39 TOWER HILL ROAD,BLDG 3 Osterville DIVER,JOHN&ANN No 1729 11707200U UNIT 9 _ __._ _...__.._._ ._. ........... ................................,._.... .............. - 117-180-20B 39 TOWER HILL ROAD,BLDG A Osterville BOWLEY,WINNIFRED E&MCSORLEY, No 1729 11718020E Q UNIT 14B ... _. ...... 117.-180:20C 39 TOWER HILL ROAD,BLDG A Osterville SULLIVAN,MICHAEL T K&TRUDY F No 1729 ._171$t120C_® UNIT 15A 117-180-20D 39 TOWER HILL ROAD,BLDG A Osterville SMALLEY,HAROLD J No 1729 11718026D Q UNIT 15B 117_-180.-20E 39 TOWER HILL ROAD,BLDG A Osterville SIRKIS,CHERYL M No 1729 UNIT 14C .............. ...... _ ................ 117-180-261 39 TOWER HILL ROAD,BLDG A Osterville GEARY,EILEEN A No 1729 11718020F UNIT 14D 117-180-20G 39 TOWER HILL ROAD,BLDG A Osterville REYNOLDS,DOUGLAS J TR No 1729 11718020E 9. UNIT 15C _......... ... ....... ........ ........ .. ._.................. ...... 117-180-20H 39 TOWER HILL ROAD,BLDG A Osterville LEWIS,SUSAN 1 No 1729 117180201.10 UNIT 15D . _ _ !.117-180-20I 39 TOWER HILL ROAD,BLDG B Osterville GAVEL,M PATRICIA&COLLINS,JENNIFER TR No 1729 . 117180201 UNIT 20B _.. _.............. ..._._..... .._... . ............ 117-180-201 39 TOWER HILL ROAD,BLDG B Osterville NULL,CYNTHIA J No 1729 117..1.802010 UNIT 20D •Map Parcel does not exist ........................................ .....-...........-. .......... .....................................-...............-_...... ......._....._ .... .............._.. ............_.... .....__........ ..._...... .............. .................. .......... ......... ................ J 2019-Town of Barnstable-Health Master TOWER HILL ROAD,Osterville-OFF MAIN ST TO POND STREET ` 1/1 f ....................................... . ........ ........ ......... Parcel(no dashes) Street no Street Village Owner name _T..._ search More Search Fields - 39 Tower Hill Road Osterville ._.. ..... ....... Reset ' m_.._ _,.....,W.d..._._. ....._........._. m_.__......—m_------_----------__ ._......... ®m Parcels Total Pages:6 Rows/Page: 10 _ Developer Sewer Parcel Location Village Owner Lot Account Index Map 117-180-20K 39 TOWER HILL ROAD,BLDG B Osterville SMIT,MARGUERITE No 1729 117180201< UNIT 20C 117-180-20L 39 TOWER HILL ROAD,BLDG B Osterville CORCORAN,KAREN A TR No 1729 .11718020L 0 UNIT 20A _ ................. 117 180 20M 39 TOWER HILL ROAD,BLDG B Osterville BOLAND,KATHLEEN TR No 1729 1171801()M.@ UNIT 21D ... ..._ _. _ 117-180.20N 39 TOWER HILL ROAD,BLDG B Osterville GRANT,CAROL A No 1729 11718020N UNIT 21A ......... .. . ...._............. ..... . .............. ........_...... 117 180-200 39 TOWER HILL ROAD,BLDG B Osterville CANUSO,SAUNIE TR No 1729 11718Q2(?0.6�J UNIT 21C .......... .. __ 117-180-20P 39 TOWER HILL ROAD,BLDG B Osterville HORGAN,ELLEN CAROL TR No 1729 11L 8020P 6� UNIT 21B .................... .... . 117-180-20Q 39 TOWER HILL ROAD,BLDG C Osterville MULLIN,KATHERINE G No 1729 11T18020Q UNIT 18A ...... .. .. ............... ........ ....... ..,., .. ............ ............. .......... ............. . .... ....,,, ,117-180-20R 39 TOWER HILL ROAD,BLDG C Osterville DOLE,ELIZABETH H No 1729 1171802OR UNIT 18B . _ ....... 117-180-205 39 TOWER HILL ROAD,BLDG C Osterville SHIELDS,JOHN T&LYNN H TRS No 1729 11718020E 0 UNIT 19A _ __... ._.__ ....._._ ........... _....... __..._. _......... ...._ 117-180-20T 39 TOWER HILL ROAD,BLDG C Osterville REILLY,WILLIAM J JR&WILLIAM J III TRS No 1729 11.778020T 0 UNIT 19B i Map Parcel does not exist ........................................ ._. ........... . ......... ......... ..._.. ........... ............................. ........... _...: .. ....__.. . - ..... ..... ...._.._ . ...._ ©2019-Town of Barnstable-Health Master TOWER HILL.ROAD,Osterville-OFF MAIN ST TO POND STREET x 1/1 i ..... ..... .... ...... ... Parcel(no dashes) Street no Street Village Owner name _ More Search Fields 39 Tower Hill Road Osterville _......_ _ Reset Parcels Total Pages:6 Rows/Page: 10 Developer Sewer Parcel Location Village Owner Lot Account Index Map 117-180-2AE 39 TOWER HILL ROAD,BLDG D Osterville TINKLER,WILLIAM G&GLORIA M No 1729 1171802AE{? UNIT 17C _..__... _ ........._.. .... ........ _ ....... ......... _._..__ _.._..._. .. .,_._...._... .. _._._....._. .._...._...i 117-180-2AF 39 TOWER HILL ROAD,BLDG D Osterville KERR,CATHERINE O No 1729 1171802AF UNIT 17D __.. ,__....._ __ _....... ....._.... ...17,-18...-2AG 39 TOWER HILL ROAD,BLDG E Osterville DWARNICK,SUSAN L No 1729 .1171842AG,„® UNIT T10 117-180-2AH 39 TOWER HILL ROAD,BLDG E Osterville MARTIN,DONALD S&JACQUELINE B TRS No 1729 1171802AH 0. UNIT Tll .. ..._...... ............. _ ...... 117 180.._2,gt 39 TOWER HILL ROAD,BLDG E Osterville BATEMAN,PHILIP C TR No 1729 1:171:80?AI.t UNIT T12 Map Parcel does not exist 0 2019-Town of Barnstable-Health Master TOWER HILL ROAD,Osterville-OFF MAIN ST TO POND STREET a 1/1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is Osterville MA 02655 Jul 6 2010 required for y every page. Cityr 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: A. General Information When filling out forms the `1 computer, r,use 1. Inspector. � vI only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mllls MA 02648 'g071 City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number License Number i 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: i ❑ Passes ❑ Conditionally Passes ® Fails t ? zi- ❑ Needs Further Evaluation by the Local Approving Authority m M �.-, July 6, 2010 Job# 10-171 �C Inspector's Signature Date m C) �- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board o C.0 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 0 o 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. C 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 )AD Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is Osterville MA 02655 Jul 6, 2010 required for y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6 2010 every page. City/town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet'but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory; for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters. due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every 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- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat`under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owners Name information is Osterville MA 02655 Jul 6, 2010 required for Y every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ , ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Unknown Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): t General Information Pumping Records: Source of information: Tank pumped within past year. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos _ Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every 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: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2 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.): Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gal Sludge depth: 3" l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every page. CityrTown State Zip Code Date of Inspection D. System Information (cont) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" 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? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, observed solids on top of outlet tee indicating hydraulic failure. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "<0 39 Tower Hill Road Building 1 d g Property Address Village Square Condos Owner Owner's Name information is Osterville MA 02655 Jul 6, 2010 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is Osterville MA 02655 Jul 6 2010 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert On 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 had previously been full to top. Unused knockouts are rotted through and box is leaking. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 U1W* 1 Property Address Ville Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: _ ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): One pit is full top top of structure and other is full to inlet pipe. Pits are in hydraulic failure. 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 r Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Ostery y ille MA 02655 Jul 6, 2010 every page. Citylrown 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.): c 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.): t t5ins•09/08 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is Osterville MA 02655 July 6, 2010 required for every page.. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately � `J�/�J I�IM LOC�7 QcJ� iwQSz�I�U �C�`i n� C�ncX t�I , oil Covers Q oI�Lr(7ACj'e J l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: N/A feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts.' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yf 39 Tower Hill Road, Building 1 Property Address Village Square Condos Owner Owner's Name information is required for Osterville MA 02655 July 6, 2010 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file } t5ins 09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts. l D�'o1=' vO Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. u Property Address .'° Village Square South Condos t.i Owner Owner's Name information is K required for every Osterville Ma. 02655 11-17-20 page. City/Town State Zip Code Date of Inspection ILO 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 f � L �• � S�� � , on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. , use the return Company Name key. 363 Whites Path r� Company Address South Yarmouth Ma. 02664 CitylTown State Zip Code 508-477-8877 S114430 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 theaime 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 OF IAq 1,, -2. ❑ Conditionally Passes O, .MICHAEL m 3. ❑ Needs Further Evaluation by the Local Approving Authority o i SEARS r y 01 No.SI14430 . 4. ❑ Fails %*%r'cFRTtF��������� S•iN.Sp�G``\``�� 11-17-20 Inspector's Si ure Date The system inspector shall submit a copy of this,inspection report to the Approving Authority (Board of Health or DEP)within30 days of completing this inspection. If the system has a design flow of �10,000 gpd or greater,rthe inspector arid 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments L,- 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. ' 02655 11-17-20 page. Cityfrown 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:, 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: 3500 gal tank, 2500 gal Fast System D Box, 100 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. El Y ❑ N. ❑ ,ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Fomm:Subsurface Sewage Disposal System Page 2 of 18 f Commonwealth of Massachusetts �n _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. u Property Address Village Square South Condos Owner Owner's Name information is Osterville Ma. 02655 .11-17-20 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): ❑ 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 Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Rd. u Property Address Village Square South Condos / Owner Owner's Name information is required for every Osterville Ma. 02655 11-17-20 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 s supply well. - El The system has a septic tank and SAS and the SAS is,less than 100 feet but 50 feet or more from a private water supply well**.` Method used to determine distance: ** This system passes if the well water;analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form: c. Other. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the.following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge'or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name_ information is required for every Osterville Ma. 02655 11-17-20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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. 1 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"C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of a tributary to a surface drinking water supply E ❑ 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 39 Tower Hill Rd. V Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. 02655 11-17-20 page. Citylrown 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 ❑ 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 El this inspection? ® ElWere 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? ® El information 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.1.5.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 .1 , Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System form - Not for Voluntary Assessments j 39 Tower Hill Rd. x U Property Address Village Square South Condos Owner Owner's Name information is Osterville Ma -02655 11-17720: required for every - page. City/Town State Zip Code Date of Inspection D. System Information 4 °` 1. Residential.Flow Conditions: Number of bedrooms (design): 16 Number of bedrooms (actual): 16 DESIGN flow based on 310 CMR 15,203 (for example: 110 god x#of bedrooms): 1760. Description: m a NA. -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 inthis report.) Laundry system inspected? - ❑ Yes E No • Seasonaluse? ❑, Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Detail: Sump pump? - ❑ Yes ® No Last date of occupancy: Da esent t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts 1v a Title 5 Offici•al Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments u- 39 Tower Hill-Rd. Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. . 02655 11-17-20 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: October 2020 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 ,tip Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h � 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is Osterville Ma. 02655. 11-17-20 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: 2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 36 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 39 Tower Hill Rd. y Property Address Village Square South Condos Owner Owner's Name information is Osterville Ma. 02655 1.1-17-20 . required for every page. City/Town State .Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 241, Depth below grade: feet Material of construction: ® concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain) 3500 gal tank 2500 gal Fast System If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of.certificate) ❑ Yes ❑ No Dimensions: v 3500 gal 1„ Sludge depth: Distance from top of sludge to bottom of outlet tee.or baffle 2911 Scum thickness 0 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 18 How were dimensions determined? Sludge judge, tape, 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.): 3500 gal tank in and outlet tees in place both covers at grade, 2500 gal Fast System both covers at grade b t 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. 02655 11-17-20 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 ❑ 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts 19- _ p Title 5 Official Inspection Form iIb Subsurface Sewage Disposal System Form Not for Voluntary Assessments �� 39 Tower Hill Rd. u Property Address Village Square South'Condos Owner Owner's Name information is Osterville Ma. _02655 11-17-20 required for every P9 _ a e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8..•Tight or Holding Tank(cont.) Alarm present: ❑_ Yes, 0 No Alarm level: Alarm in working order: ❑ Yes [] .No Date of last pumping: bate 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 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 36x36 with 14 outlets, box has pump to Fast System, cover at grade .i 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 h Subsurface Sewage Disposal System m Form Not for Voluntary Assessments 9 P Y rY �j 39 Tower Hill.Rd: � Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. 02655 11-17-20 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: s Type: ❑ leaching pits 7 ,number: ® leaching chambers. number: 100 } ❑ leaching galleries number: ❑ . leaching trenches number, length: ❑ a 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 I- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is Osterville Ma. 02655 11-17-20 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of , vegetation, etc.): SAS is 2 sets of Biodiffusers stoneless chambers are clean and dry with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer + Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic'failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. 02655 11-17-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (coat:) 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.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts -- W Title 5 Official 'Ins, p ection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is required for every Osteryille Ma._ 02655 11-17-20 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 Y. 5 EPTj c O . I . 2 !,y f eke FAST � I „ sex i co .51'c 'A Alh£ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts .b �n Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 39 Tower Hill Rd. u Property Address Village Square South Condos Owner Owner's Name information is Osterville Ma. 02655 11-17-20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells s Estimated depth to high ground water: 13+ ` .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:, 5-3-2010 Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: 0 Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS"database explain: You must describe how you established the high.ground water elevation: No ground water per plan 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 �n Title 5 Official Inspection Form + i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 39 Tower Hill Rd. Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville Ma. 02655 11-17-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section., ® B. Certification: Signed & Dated.and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate _ 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included - I t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 r . /i 5 - ova - DCA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments rr, 39 Tower Hill Road (BLDG 1&2) ; Property Address Village Square South Condos Owner Owner's Name x x information is required for every Osteryille MA 02655 8-15-17 page. City/Town State Zip Code Date of Inspection IVY 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 WhenWhen fillip out f A. General Information s/ a$�� ,,,►�tttfllll,�,,,, `� �tH OF MAS on the computer, �� use only the tab key to move your 1• Inspector: ,=ar,• ; cursor-do not DAMES N' James D.Sears s i" use the return ke Name of Inspector y Capewide Enterprises •'• _Q Company Name ��iJ>w��F s�G % 153 Commercial Street ��nni NtSP1a```��` Company Address Mashpee MA 02649 Cayt I own State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: E Passes . ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority c� 8-9 5-17 pector'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 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.doc-rev.6116 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /o d VS g l, abed xeJ dH £04,6 L 60Z L l, 6rT1 Commonwealth of Massachusetts Title 5 Official Inspection Form MOWA b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 5-15-17 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is 3500 Gal. Tank 2500 Gal. D Box and 100 chambers. System is a micro fast system. System is for BLDG 1&2. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below); t5ins.doo•rev.6116 Tlfie 6Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 61, a5ed Xe:1 dH b0:V 6 L XZ L 6 End f Commonwealth of Massachusetts � Title 5 Official Inspection Form ME Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) properly Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-15-17 page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms 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 i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ina.doc-rev.6116 Title 5 Of ial Inspavien Form:Subsurface SeArage Disposal Syslarn-Page 3 of 17 OZ a5ed xeJ dH b04,6 L 60Z L 6 5n`d i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner owner's Name information is required for every Osterville MA 02655 B-15-17 page. Citylrown 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 11 ® 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 ink is less than 6" below invert or available volume is less than Y2 day flow 1 E,4014 t5ins.doc-rev.6116 Title 5 Official Inspectien Form:Subsurface Sewage Disposal System-Page 4 of 17 6Z a5ed Xed dH .b0:b 6 L I OZ L l• 5nV i Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-15-17 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- 10,000gpd. ® The system falls.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. . _ E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either".yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department, t54ns.doc-rev.6116 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ZZ a6ed xed dH SUV I. L 60Z L I. 6ny I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 8-15-17 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 16 Number of bedrooms(actual): 16 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 1760 t5ins doc rev.6A6 Title 5 Official Inspection Form:Subsurface Seweae Disposal System-Page 6 of 17 £Z e6ed xeJ dH 90:t 1, L 1,2 L 1, 5nV i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) _ Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-15-17 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 3500 Gal.Tank,2500 Gal. Tank, D Box and 1000 chambers. System is a micro fast system. System is for BLDGS 1&2. Number of current residents: NA 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: dlne.doc•rev.6116 Title 8 Official Inspecticn form Subsurface Sewage Disposal System•Page 7 of 17 bZ abed x2J dH 90:b 1, L 60Z L I• bnV Commonwealth of Massachusetts own Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): 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 ❑ 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): t5lns.doc-rev.6.116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page a of 17 SZ a5ed xeJ dH 90:t7 6 L 60Z L I. 5nV f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner owner's Name informationairedfor is Osterville MA 02655 8-15-17 required forevery page. City/Town State Zip Code Date of I nspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Pipeing is 6"cast iron BLDG to tankother pipein 4" PVC SCH 40.. 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: 3500 Gal. - 2500 Gal. III 0il Sludge depth: LSins.doc•ray.&16 Title 5 Official Inspection Form:Subaudace Sewage Disposal System-Page 9 of 17 gz a5ed xe� dH L6t l, L M L I. 5nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 B-15-17 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 1 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 9" Distance from bottom of scum to bottom of outlet tee or baffle 43" How were dimensions determined? Plan-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.): Main tank 3500 Gal, H-20 Precast wlboth covers steel at grade in grass area. C.I. inlet tee,outlet tee. No sign of over loading. 2500 Gal. H-20 precast wfticro fast system. Both covers steel at grade, tank clean. Grease Trap(locate on site plan): Depth below grade: Beet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 151ns,doo-rev.6/16 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 LZ a5ed xe:1 dH L&V 6 L 1,0Z L 1• 5nV M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road(BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float.switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.0116 Tile 5 Official Irtspectim Form:Subsurtaes Sewage Disposal System•Page 11 W 17 gZ a5ed x2J dH LO:b 6 L lOZ L 6 5nV Commonwealth of Massachusetts None Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02656 8-15-17 page. City/Town State Zip Code Date of Inspedion 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 w114 outlet's. Steel cover at grade in grass area. D Box has a recirc pump for fast system. 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: 15ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Dlsp sal System-Page 12 of 17 6Z abed xed dH 80:b 6 L 60Z L I• bnb I Commonwealth of Massachusetts Title 5 Official Inspection Form laww ;\V�J' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road BLDG 1&2 Property Address Village Square South Condos Owner Owners Name information is OSteNllle required for every MA 02655 8-15-17 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont,) Type: ❑ leaching pits number: ® leaching chambers number 100 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two set's of 50 ARC , 36 HC H-20 Biodiffuser's stone less total 100 chambers.Camera out to chambers, Chambers are clean and wet No sign of over loading or holding water. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6116 Tit.a 5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 17 06 a5ed xed dH 80:t l, L 60Z L l, 5nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02656 8-15-17 page. City/Tom 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,): t5ns.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal SySlern•Page 14 or 17 6£ a5ed xed dH 80:t71, L 60Z L 6 6rf1 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 1&2) Property Address Village Square South Condos Owner Owner's Narne information is Osterville MA 02655 8-15-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately S EPT C_ 7i4NK aC W M t coo Fi9Sr .�AAl 'D ^1h. ox C ovE'0 f Li �FcK i4r r,40 F tsine.doa•rev.8116 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 or 17 Z£ a6ed xe� dH 80:b 1• L 1.02 L 6 find N, Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 1&2) Property Address Village Square South Condos _ Owner Owners Name information is required for every Osterville MA 02655 8-16-17 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� 13'+ Estimated depth to sigh ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6-3-2010 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 8-3-10 no G.W. at 13'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. f5ins.doc.rev.6116 Title 5 official inspecmn Form:Subsurface Sewage Disposal system-Pape 16 of 17 ££ a5ed xeJ dH 60:b I. L 60Z L l, End Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road BLDG 1&2 Property Address Village Square South Condos Owner owner's Name information is required for every Osterville MA 02655 8-15-17 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 l5ins.doc•rev.6115 Tire 5 Oftal Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ti£ abed xe� dH 60:b i, L 60Z L l, srnd ep 0714 07:47p p,1 t Commonwealth of Massachusetts- - - Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road:_BLDG 1 &2 Property Address, Village Square South Condos Owner Owners Name -- — information is Osterville MA 02655 8-29-14 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 and of the form. Important:when filling out forms A. General information ` ttt�a►trtOr4fl�rUi • on the computer, H of Q4 use only the tab V/ `�� •••... key to move your 1. Inspector ,. 0o�+ �yG� cursor-do not James D.Sears JAMES m use the return Name of Inspector p. s cokey. CapewideEnterprises,LLC i•'•,o o # Company Name 153 Commercial Street Company Address rrnrnrn ►a't Mash�ee=_ MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 , Telephone Number y A 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 0 Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ' 8-29-14. nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to.the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to,the buyer, if applicable, and the approving authority. . **"*This report only describes conditions at the time of inspection and underthe 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.. t5in3•3113 _ Title 5 Official Ompeclion ubsurface Sewage Disposal System•Page 1 of 17 Sep 0714 07:48p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 c Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-29-14' page. City[Town State Zip Code Dale of Inspection B. Certification (cunt.) " x Inspection Summary: Check A,8,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 3500 Gal.Tank,2500 GaL Tank D Box and 100 Chambers. System is a micro fast system. System is for BLDG 1&2. B) System Conditionally Passes. ❑ One or more system components+as*described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for'yes","no"or"not determined'(Y,'N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing.tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass.inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that.the tank is less than 20 years old is available. ❑ Y ❑ N _ ❑_ND(Explain below): t51r s 3 13 - y Title 5 otrdai Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t , Sep 071,4 07:48p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos Owner Owner's Name information is required for every Osteryille r MA' 02655 8-29-14 page. Citylrown State Zip Code Date of Inspedion B. Certification (cont.) ❑ Pump Chamber pumps/alarms not opeiational.'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 r 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): ❑ distributon,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 4 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-3113 TiVe 5 Official Inspection. Fom;Subsurface SewsSa Disposal S yem'Page 3 aF 17 Sep 0714 07:48p p 4 Commonwealth of Massachusetts _ 0 Title 5 Official Inspection - Form aii, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- '( 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 8-29-14 page. CityRown State Zip Code Date of inspection B. Certification (cont.) :1 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 AII'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 4 or clogged SAS or cesspool Liquid depth in asopM is less than 6"below invert or available volume is less " t than %day flow 4 t Xe'111 vG t5ins 3113 Title 5 Otfidai inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Sep 0714 07:49p p.5 Commonwealth of Massachusetts ' Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 8-29-14 required for every ' page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: El ® 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 of 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.] ❑ 0 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. r 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. . t For large systems, you must indicate"either"yes"or"no"to each of the following, in addition to the questions in Section 0. Yes No k ❑ ❑ 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 Zoneal 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 mns•w 3 Title 5 Official Inspection Form;Subsudaee Sewage Disposal System•Page 5 of 17 Sep 0714 07:49p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 11& 2• Property Address Village Square South Condos Owner Owner's Name _ - -- information is required for every Osterville M MA 02655 8-29-14 ; page. CityfT own 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? Z ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered opened, and the interior of the tank - inspected for the condition of the baffles or tees,*material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board'of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Informatjon, e oNL)o •-`Tug a ,ate D s, Residential Flow Conditions: Number of bedrooms(design): t 16 Number of bedrooms(actual): - 16 DESIGN flow based on 310 CMR 15.203 for exam le: 110 1760 . ( _ p gpd x#of bedrooms): t5iis•3/13 • Tiae 5 Official Inspection Fom Subsurface Sewage Disposa°System•Page 61of 17 Sep 07 1,4 07:49p _ p.7 Commonwealth of Massachusetts k Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 ' Property Address Village Square South Condos Owner Owner's Name information is oSterville MA 02655 8-29-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 3500 Gal.Tank, 2500 Gal Tank, D Boz and 1000 chambers. System is a micro fast system. System is for BLDG 1&2. Number of current residents: _ NA Does residence have a garbage grinder?. t. ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes „No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑, Yes ® No Water meter readings, if available (last 2 years usage(gpd)): a 2012-2,261.000G 2013-1,946.000Gal Detail: — Sump pump? ❑ Yes ® No Last date of occupancy: Present p Date Commercial/Industrial Flow Conditions: Type of Establishment: " Design flow(based on 310 CMR 15.203): Gallons per day(spd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? t . - 0 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•3113 Title S Official Inspection Form:Subsurfaoe Sewage Otsposat System-Page.7 of 17 Sep 0714 07:50p p.8 Commonwealth of Massachusetts. Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 & 2 Property Address Village Square South Condos w Owner Owner's Name information is required for every asterville MA 02655 8-29-14 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): Generallnformation Pumping Records: Source of information: Was system pumped as part of the inspection?, ❑ Yes ® No If yes, volume pumped: "« • � gallons = How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ -Single cesspool . ❑ Overflow cesspool Privy ❑ Shared system (yes or no),(if yes, attach previous inspection records, if any) r ® Innovative/Altemative 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 dopyof the DEP approval. ❑ -Other(describe): , - _ Title 5 Official 1 pion Form:SubsWaos Sewage I• � ge Disposal System•Page 8 or 17 Sep 0714 07:50p p,9 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 Property Address -- Village Square South Condos' Owner Owner's Name information is Osterville MA 02655 8-29-14 required for every, ; page. Citylrown state Zip Code Date of Inspection D. System Information (coat.) Approximate age of all components, date installed (if known)and source of information: 2011 Were sewage odors detected'when arriving at the site? ❑ Yes 19 No Building Sewer(locate,on site plan): t Depth below grade: 3 tees` Material of construction:;" ® cast iron ® 40 PVC D other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing 6" cast iron BLDG to tank other pipein 4" PVC SCH 40.1 Septic Tank(locate on site plan). r' Depth below grade:' .' feet Material of construction: ' ® concrete ❑' 6tal ❑ fiberglass r❑Ypolyethylene other(explain) If tank is metal, list age: years Is age confirmed by.a'Certificate of Compliance?.(attach a copy of certificate) _ " ❑Y Yes ❑ , No Dimensions: j 3500 Gal. -2500 Gal. Sludge depth: on t9ns-3ft3 ° Tide 5 Cffidaa InsFecton Form:Subsurface sewage uis al. System-Page 9 of 17 Sep 0714 07:50p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments is 9W, 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos Owner Owners Name information is Ostervllle required for every MA 02655 8-29-14 page- Cdyfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cost.) Distance from top of sludge to bottom of outlet'tee or baffle Scum thickness Distance from top of scum to to 9" p of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle 43 How were dimensions determined? Plan-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_):. Main tank 3500 Gal. H-20 Precast wl Both covers steel at grade in grass area.C.I. inlet tee, outlet tee. No sign of over loading, 2500 Gal H-20 precast w/micro fast system. Both covers steel at grade tank clean. Grease Trap(locate on site plan):•. f Depth below grade: feet Material of construction: ' ❑concrete ❑ metal []'fiberglass ❑ polyethylene ❑other(explain): Dimensions: ;F Scum thickness Distance from top,of scum'to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ~ Date +45ins•3l13 Title 5 pgciat,inspevion Form:suo5urrace Sewage Usposal System•Patte 16 or 17' Sep 0714 07:51 p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 & 2 Property Address — Village Square South Condos : Owner Owners Name information is required for every Osterville _ MA 02655 8-29-14 page. Cityrrown State Zip Code Date of Inspedion 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: El Yes [I No Date of last pumping: Date Comments(condition of alarm and float`switches, etc.).'. ° `Aftach copy of current pumping contract(required). Is copy attached Z, ❑. Yes ❑ No t5lns•3/13 - - Title 5 Official inspection Form:Subsurface Sewage Disposal System page 11 of 17 Sep 0714 07:51 p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System_Form -Not for Voluntary Assessments 4 't 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos i Owner - information is Owner s Name • required for every Osteryille Y MA 62655 8-29-14 page. CRylTown '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 B 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 w/14 outlets. Steel cover at grade in grass area. D Box has a recirc pump for fast system. - Pump Chamber(locate on site plan): Pumps in working order: ❑ 'Yes ❑ No* Alarms in working order: El 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: 15ins'3/t3 Title 5 Official InspeGion Form Subsurlace Sewage Disposal system•Page 12 of 17 r » Sep 0714 07:51 p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form % sessmen Subsurface Sewage Disposal System Form -Not for Voluntary Asts 39 Tower Hill Road BLDG 1 &2 Property Address Owner Village Owners Namellage Square South Condos - information is - required for every Osterville MA 02655 8-29-14 4 page. City/Town State Zip Code Date of Inspection D. System Information (cost:) Type: ` ❑ leaching pits number: ® leaching chambers number:- 100 ❑ leaching galleries fi .•number: ❑ leaching.trenches number,length: ❑ leaching fields number;,dimensions T. ❑ overflow cesspool R number: ❑ innovative/alternative system Type/name of technology', Comments(note condition of soil, signs of hydraulic failure, level'of poriding, damp soil; condition of vegetation, etc.): Leaching is two secs of 50 ARC ,36 HC H-20 Biodiffuser's stone less total100 chambers. Camera out to chambers, Chambers are clean and.wet.•No sign of over loading or holdingwater Cesspools (cesspool must be p6miped as p art of inspection)( locate on site lar - Number and configuration j f Depth—top of liquid to inlet,invert ` Depth of solids layer ; .F Depth of scum layer'_ Dimensions of cesspool _ Materials of construction = _ Indication of groundwater inflow ❑ Yes ❑ No t5ins•3l13 - Tilie 5 Offidal Inspection Form Subsurface Sewage Disposal System•Page 93 of 17 t ' Sep 071,4 07:52p _ p.14 Commonwealth of Massachusetts - Title 5 Official Inspection Forme _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos Owner Ownees Name information is required for every OStefVllle MA 02655 8-29-14` page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure level of ondin condition f v etc.)_ - 9 Y p g, o vegetation, w Privy(locate on site plan): - Materials of construction: • r Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,'condition of vegetation, etc.)-. 4 . 15ins-3113 Title 5 OfFciai hspecton Form:Subsudece Sewage USPOSd System•Page 14 oT 17 n Sep 071.4 07:52p _ p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form i -- - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 39 Tower Hill Road BLDG 1 &2 Property Address - — --------- Village Square South Condos Owner Owner's Name —: infonnation is required for every Osterville "MA 02655 8-29-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1 DO feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below f. k SE?Tic �,gtier a ; 0. Iv I�I� CR� rl�ST ° j rn Q 0 , p ' co Stns•3i 3 Title 5 Offdal Inspedia�Form:Suhstxfaut Snw Apo Dispoed Sysfom•Dn90 15 of 17 Sep 07 1,4 07:52p p.16 • Commonwealth of Massachusetts UL Title 5 official . Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 &2 Property Address Village Square South Condos Owner Owners Name information is required for every Osterville MA 02655 8-29-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt:) Site Exam: -❑ Check Slope ❑ Surface water - 4 ❑ Check cellar ❑ Shallow wells �a t Estimated depth tofWi-gh ground water: 13'+ 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: 8-3-2010 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 8-3-1d no G.W.at 134 • Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•imI Tina 5 Offidel Ingmdion Foffrc Subsurface Sewage DiWsal System•Page i6 o117 Sep 071,4 07:53p p.17 Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 1 8i 2 Property Address Village Square South Condos '.. Owner Owners Name , information is required for every Osterville MA 02655 8-29-14 page. Citylrown 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 jx 1 ,:4 tShS•3113 Title 5 Official InspeclionForm:Subsurface Sewage Disposal System•Page 17 of 17 j Cx as a . COMMONWEALTH OF MASSACHUSETTS ss `O��� U� ��a0136 s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS L`� TABS DEPARTMENT OF ENVIRONMENTAL PROTECTIOW05 JUN Z$ AM 9: 5 . OCI!tlSlON TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Units 1A-D and 2A-D(Septic System #4) Property Address: 39 Tower Hill Road Osterville. MA 02655 Owner's Name: Village Square South Condominium Association Owner's Address: P.O. Box 598 1 Osterville. MA 02655 Date of Inspection: June 11, 2005 Name of Inspector: (Please Print) James M.Ford Company Name: James M.Ford . Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT 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 4NeedsFurther Evaluation by the Local Approving Authority Inspector's Signature: Date: June 13, 2005 The system inspector shaysubaof 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 1 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 1A-D&2A-D)-System#4 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer,yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units IA-D&2A-D)-Svstem#4 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units IA-D&2A-D)-System#4 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 'h 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Tower Hill Road(Units IA-D&2A-D)-Svstem#4 Osterville. MA Owner: Vi11aQe Square South Condominium Association Date of Inspection: June 11, 2005 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Tower Hill Road(Units 1A-D&2A-D)-System#4 Osterville MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 16 Number of bedrooms(actual): 16 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: n/a Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Some units Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped yearly for maintenance-Pumped approx. 6 weeks ago for maintenance Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approximately 1972-per design plans Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units lA-D&2A-D)-System#4 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 3500 Qal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 44" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: _Measuring stick Conunents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be anv signs of leakage The steel covers were to grade. The tank was pumped for maintenance approximately 6 weeks ago ` GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units lA-D&2A-D)-Svstem#4 Osterville MA Owner: Village Square South Condominium Association Date of Inspection: June 11 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units IA-D&2A-DI-Svstem#4 Osterville MA Owner: Village Square South Condominium Association Date of Inspection: June 11 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 3 -6'x 6'with 5'stone(per design plans) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Two of the nits 04 and#5)had approximately Y ofliquid on the bottom The other pit 03)was dry There did not appear to be any signs offailure. Steel covers were to grade The bottom to Zrade was 12' CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units JA-D&2A-D)-System#4 Osterville. MA Owner: _ VillaQe Square South Condominium Association Date of Inspection: June 11, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. (�U, ------ A(3� a 39 Sb 30 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units JA-D&2A-D)-System#4 Osterville, MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 43 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours mans the maps were showing approximately 43'+/ to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection andlor this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS• r f DEPARTMENT OF ENVIRONMENTAL PROTECTION F' ONE WINTER STREET,BOSTON MA 02108 '(617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI ' DAVID B.STRUIiS Governor F Commissioner SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION Septic System/W x ' Property Address: 39 Tower Hill Road, Osterville, MA' Name of Owner: . Village Square South Condominium Association Units IA, 1B, IC, 1D, 2A, 2B, 2C&2D Address of Owner: P.O. Box 521 Osterville, MA 02655 Date of Inspection: March 1, 1999 _ Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of.Titie 5(310 CMR 15.000) W' Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 . Map: '117 Telephone Number: (508)862-9400 Parcel.-V 072 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system ✓ Passes Conditionally Passes y47 ; . Needs Further Evaluati the Local Approving Authority ails Inspector's Signature: Date: F March 7, 1999 The System Inspector shall subnI copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the, system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS 12 d . au APR 9 1999 r toMOF CP revised 9/2/98 Page I of II Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA (Units IA, IB, IC, ID, 2A, 2B, 2C&2D) Owner: Village Square South Condominium Association Date of Inspection: March I, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 obstruction is removed V t revised 9/2/98 Page 2ofII r , 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM' - PART A CERTIFICATION,(continued) tr Property Address: 39 Tower Hill Road, Osterville,'MA (Units ]A, IB, IC,''ID, 2A,.2B, 2C&2D) Owner: Village Square South Condondnium Association ; Date of Inspection: March 1, 1999 y 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 toprotect•the- public health, safety and 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 THE PUBLIC HEALTH AND' SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water. e Cesspool or privy is within 50 feet of a bordering vegetated wetland'or'a salt marsh. 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 AND SAFETY AND THE ENVIRONMENT: e The system has a septic tank and soil absorption system(SAS)and the SAS is within'100 feet to a surface water supply or tributary to a surface water supply. . The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of.apublic water"supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water' supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the, well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation1not valid). 3) OTHER S .i. tl��• •. `-_" ` w, a .. .. i .. revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM' INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA (Units]A, IB, IC, ID, 2A, 2B, 2C&2D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 '/a 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable attach copy of well water analysis for conform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of II I - , I SUBSURFACE SEWAGE'DISPOSAL-SYSTEM- INSPECTION FORM PART B 'CHECKLIST, .' Property Address: 39 Tower Kill Road, Osterville, MA (Units IA, IB,.1(7, 1D,1A, 2B, 2C& 2D): Owner: Village Square South Condominium Association _ s Date of Inspection: March 1, 1999 Check if the following have been done: You must indicate either "Yes or "No" as to each of the,following: ' Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for of least two weeks and the system has been receiving normal flow. rates during that period. Large volumes of water have not.been introduced into the system recently or:as.part of this-,., inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A r ✓ _ The facility or dwelling was inipected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout ✓ All system components, excluding the Soil Absorption System,have been located on the.site. , ✓ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example,-Plan at B.O.H.` ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) F [15.302(3)(b)] y ✓ _ The facility owner(and occupants,if different from owner)'wereprovided with information on the proper maintenance of SubSlrrface Disposal Systems. « , revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Tower Kill Road, Osterville, MA (Units IA, 1B, IC, ID, 2A, 2B, 2C& 2D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: _g.p.d./bedroom Number of bedrooms(design): Number of bedrooms(actual): _ Total DESIGN flow Number of current residents: grinder(y or no):Garbage d es — Laundry(separate system)(yes or no): _; If yes, separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last two yearg;usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Residential Condominiums (16 bedrooms) Design flow: 1600 gpd(Based on 15.203) Basis of design flow 50 gpd per person-2 persons per bedroom (see design plans) Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system (yes or no) No Water meter readings, if available: 1998-184,000 gals.; 1997-171,000 gals. Last date of occupancy: Currently occupied. OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pwnped once per year for maintenance-per Manager. System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of,all components,date installed(if known)and source of information: 1972-per design plans. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6ofII I SUBSURFACE;SEWAGE,DISPOSAL SYSTEM INSPECTION FORM i. PART C • SYSTEM.'INFORMATION (continued) Property Address: 39 Tower Hill Road, Osterville MA (Units IA, IB,'I C, ID,`24, 2B, 2C& 2D) Owner: Village Square South Condominium Association" Date of Inspection: March 1, 1999 BUILDING SEWER: (Locate on site plan) Depth below grade: „ Material of construction: _cast iron _40 PVC _other(explain)' Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting',evidence of leakage;etc.) P 4. SEPTIC TANK ✓ (locate on site plan) Depth below grade: Covers to tirade Material of construction: ✓concrete metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: _14'x 7' x 6'9" (3500 gall Sludge depth: 5" , Distance from top of sludge to bottom of outlet tee or baffle: 43 Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: •9" "•r Distance from bottom of scum to bottom of outlet tee or baffle: 15 How dimensions were determined: Measuring stick Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles;depth of liquid level in relation to outlet invert, structural integrity; evidence of leakage, etc.) The tees were present. The liauid level was even with the outlet invert There were no signs of leakage GREASE TRAP: None } (locate on site plan) . . Depth below grade: ; Material of construction: ®concrete _metal '_Fiberglass Polyethylene '_other(explain) - Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:` :;. '`• _ x , Distance from bottom of scum to Bottom of outlet tee or baffle: ;.r Date of last pumping: r r Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles;depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.)" revised 9/2/98 _ Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Kill Road, Osterville, MA (Units IA, 1B, 1C, ID, 2A, 2B, 2C& 2D) Owner: Village Square South Condominium Association , Date of Inspection: March 1, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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/day Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: 0' even Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level and there were no signs of solids carryover. PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order. (Yes or No) Continents: (note condition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8otll SUBSURFACE SEWAGE,DISPOSAL•SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION (continued)^ -. Property Address: 39 Tower Hill Road, Osterville,>MA (Units]A, 1B,-'IC,"ID,•2A, 2B 2C&2D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required; location inay be approximated;by non-intrusive methods) If not located,explain: Type: leaching pits, number: 3 leaching chambers,number: " leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Alternative system Name of Technology: Cotmnents: . (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.) The leaching pits were 6'x 6'with S'of stone per the design plans. The bottom to grade was 12'. One pit was full: Grass covered the system CESSPOOLS: None (locate on site plan) ` .. wia' Number and configuration: 4` Depth-top of liquid to inlet invert: j Depth of solids layer: ' Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of.inspection) Comments: (note condition of soil,signs of hydraulic failure,level of pondiiig,condition of vegetation,etc.) PRIVY: None (locate on site plan) r Materials of construction: -�. ''"'Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA (Units 1A, 1B, IC, ID, 2A, 2B, 2C&2D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 Map: 117 Parcel. 072 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply conies into house) , ` Q J 40 Q Q � h f w QI uo ,T ,M00'M � -m �� o U � m ' Q ' f � C —O 7 d i n. Q Ct revised 9/2/98 Page 10of 11 I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART C SYSTEM INFORMATION (continued) v Property Address: 39 Tower Hill Road, Osterville, MA(Units'IA, 1B; IC, ID, 2A, 2B, 2C Bc 2D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 _ + NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate - Deep.. -. SITE EXAM Slope " Surface water Check Cellar ' Shallow wells r Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: t Obtained from Design Plans on record Observed Site(Abutting property, observation hole;basement sun p etc:) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps ' Checked pumping records T Check local excavators, installers , ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable water table and topographic maps,'the maps were showing approximately 43' fo•groundwater „ at this site. This report has been prepared and the system inspected and passed as of the date of inspection. ;This report is not a warranty or,guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to.the system, the inspection and/or this report. revised 9/2/98 - Page 11 of 11 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) Property Address .0 Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4.19 per, City/Town State Zip Code Date of Inspection s,r F 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. t11111111 I l l r!p/� Important:When filling out Forms A. Inspector Information ��# ,.N`�°�� Ass'1*-1 on the computer; , use only the tab James D.Sears ?�: JAMES �' key to move ur Name of Ins ctor o; :-{_ currsor-do not SEARS use the return Capewide Enterprises # key. Company Name mil'•ip FRTiF�'� ' 153 Commercial Street Nei s'1 N'gpE�'��.�`�� Company Address 11111mM ? Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623' Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11-5-19 A. pector'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. t5fnsp,doc•ray.7/26/2018 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 0t, a5ed xeJ dH 2:00 660E 90 AON f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vy 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owners Name required for is every Osterville required for eve MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3,or 5 and all of 4 and 6. 1) System Passes: ®_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank and two pits 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.7f2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 It, a6ed xed dH 000 61,2 g0 AON i Commonwealth of Massachusetts Title 5 Official inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owner's Name information is Osteryille MA 02655 11-4-19 required for every page. City(Town State Zip Code Date of Inspection C. Inspection Summary (cost.) 2) System Conditionally Passes (conL): ❑ Pump Chamber pumpsJalarms 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-fey.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of'8 Zb 95ed xed dH 9Z:00 6 60E 90 AON Commonwealth of Massachusetts Title 5 Official Inspection Form ([e 9 Subsurface Sewage Disposal System Form •Not for Voluntary Assessments C Lys 39 Tower Hill Road(BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank,and SAS and the SAS is within a Zone 1 of a public water supply, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *`This system passes if the well water analysis,performed at a DER 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 I5insp.doc rev.7.'26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 �� a5ed XeJ dH 9E:00 61,OZ 90 AoN 4 Commonwealth of Massachusetts Title 5 Official Inspection Form t (( Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in amu pu*is less than 6"below invert or available volume is less than 1/2 day flow lit ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® 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 fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or`no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone ll 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 bt, @lied xeJ dH 9F:00 660Z 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form t�} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F., 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owners Name information is required for every Osterville MA 02655 11-4-19 page. Cityrrown 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: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The 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.712 612 01 8 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 18 Sb abed xeJ dH 9Z:00 MZ 90 AON Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 3) Property Address Village Square Condos Owner Owners Name information isequired or every very Osterville MA 02655 11-4-19 page. Oty/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 880 Description: 1500 Gal.Tank and two it's. r ' Number of current residents: NA 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)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy. Present Date tBlnsp.doc-rev.7128201E Tine 501cial Inspection Farm:Subsurface Sewage Disposal System•Page 7 of 18 gt, a5ed xed dH 9F:00 660Z 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow.(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq,ft„ etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit,present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7!2612018 Title 5 Official Inspection Form:Subsurface SeHage Disposal System•Page 8 of 18 L� abed Xed dH LZ:00 660Z 90 ^ON Commonwealth of Massachusetts k1rw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 39 Tower Hill Road(BLDG 3) Property Address Village Square Condos Owner Owners Name information is Osterville required for eve MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspe0on 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/Altemative 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): 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.): Pipeing is inlet line 6"cast iron, outlet 4" PVC SCH 40 t5lnsp.doc•rev.TQagoi8 Title 5 Official Inspection Form:Subsueace Sewage Disposal System-Page 9of le gb a5ed xed dH L2:00 660Z 90 ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) Property Ada ress Village Square Condos Owner Owners Name information Is required for every OSteNill@ MA 02655 11-4-19 page. Gty[To`n+n State Zip Code Date of Inspection D. System Information (cont) 6. Septic Tank(locate on site plan): Depth below grade: 1' feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other{explain} If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" � Scum thickness 8. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17.E 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,); Tank at working level, outlet cover steel at grade in grass. Inlet cover under brick walk. Inlet and outlet tee's. No sign of leakage or over loading t5insp.doc•rev.7/2612018 Title 60fficial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 6t, abed Xej dH L2:00 61,OZ 90 AoN Commonwealth of Massachusetts � Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road BLDG 3 19P. Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. Clty/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 t5inap•doc•rev.7/2E/201B Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of I og a5ed Xed dH LZ:00 6 XZ 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'y7 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA O2655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Box 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.): t5lnsp.doc•rev.7126/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposa System-Page 12 of 18 65 abed YU dH K00 61.0Z 90 AoN Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F, yr 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owners Name information is required for every Osterville MA 02655 11-4-19 page. Cltylrown 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: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternativesystem Type/name of technology: t5insp.doc•rev.7!2812018 Title 5 Official Inspection Form:Subsurlaos Sewage Disposal System•page 13 of 18 Zg a5ed xed dH Woo 660Z g0 AoN Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /t 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owners Name information is Osterville required for every MA 02655 11-4-19 page. Crty/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 two H-20 precasts pits in black top parking area piped in line w/steel cover's at grade. Pit#1 at 28"below grade.4'water in pit. Pit#2 at 35" below grade dry. 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.): Gnsp.doc•rev.7/28!2078 Title 50111dal Irspectim Form:Subsurface Sewag e Disposal System•Page 14 of 18 £g a5ed XeJ dH 8E:00 660Z g0 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L: •� 39 Tower Hill Road(BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation, etc.): tSinsp.doc.•rev.7/28/2018 Title 5 official Inspection Form:Subsurface Sewage Disposer System•page 1S o/18 �� a5ed xed dH R:00 6 Xe 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) _ Property Address Village Square Condos owner Owner's Name information is Ostervilie \ MA 02655 11-4-19 required for every --.. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately . �? I` eu� 1 4.= s 7 LOT, G�AA L i O • 0 3 I Ifilw.6oC•ni 5i1tl , TIOe 3 11roee IClpwar Form 9wu•(eee aMepu IMSMIW 37.-em•Pilpe t pr it 5g a5ed XeJ dH ROO 6 Xe 90 ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form tI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water: 13'-6" 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: B-3-10 Date ❑ Observed site(abutting propertylobservation hole within 160 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.8-3-10 no G.W.at 1 T-T. Before filing this Inspection Report, please see Report Completeness Checklist on next page. tbinsp.doc;rev.7/26/2018 Title 5 Official Inspeallon Form:SuhsLrfaw Sewage Disposal System Page 17 of 18 gg abed xeJ dH 82:00 61.0Z go ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary 9 p y Assessments i% 39 Tower Hill Road (BLDG 3) Property Address Village Square Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 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 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 U ' � ,�e17o,M Pry S �. 15insodoc•rev.7/22612018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal system•Page is of 18 Lg a5ed xed dH K00 660Z 90 ^oN r _ ® �)v 17 2016 14:58 Jim The Inspector Man 5085349919 - page 1 �■ Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsC> I C w 39 Tower Hill Road(BLDG3) Nroperry Address .. z Village Square South Condos Owner Owner's Name - information is QStefVllle required for every MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection � G•a Inspection results must be submitted on this form. Inspection forms may not be altered in any I way. Please see completeness checklist at the end of the form. Important:When ti A. General Information I filling out forms SI I ` 0%1111111 � s use computer,only he tab OC c��'��O�MgsS�'���i key to move your 1. Inspector: o�ya ,. cursor-do not yG James D.Sears JAMES ,_ use the return key. Name of InspectorCos = Ca ewide Enterprises, LLC ®y Company Name t i 153 Commercial Street '%,F S INSPE�'���`��`` i Company Address �► Mashpee MA 02649 wn State Zip Code _ 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the-time of the inspection. The inspection was performed based on my training and experience in the properfunction'and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails . - ti ❑ Needs Further'Evaluation by the Local Approving Authority 11-14-16 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system 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 a the same or different conditions of use. i5ins.doc•rev.6/16, Tide 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 Nov 17 2016 14:58 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments' 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos I . Owner Owner's Name - information isequired or every very Osterville MA 02655 11-14-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont,) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not hound 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 1600 Gal. Tank and two pits B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.-The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I 15ins.doc•rev._6f1ti Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 2 of 17 I Nov 17 2016 14:58 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill R_oad(BLDG3) Property Address Village Square South Condos Owner Owner's Name information required for every Osterville MA 02655 11-14-16 page. . Cityrrown 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 outlor 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 I ❑ Y ❑ N ❑ ND (Explain below): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6)16 - Tills 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Nov 17 2016 14:58 Jim The Inspector Man 5085349919 . page 4 : i Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w r 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name Information is required for every Osterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is.functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within.50 feet of'a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis; performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool I,A'❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 0 ® Liquid depth in 455111P111111111is less than 6" below invert or available volume is less than %day flow P,r rs 15ins.doc•rev.6116 1itle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Nov .17 2016 14:58 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owners Name information is I required for every Osterville MA 1 02655 11-14-16 page: City/Town State! Zip Code Date of Inspection B. Certification (cont.) t 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. 0 ® 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.doc-rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System Page 5 o117 Nov 17 2016 14:58 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owners Name information is required for every psterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No i ❑ 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 mal intenance 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): 8 8 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880 I51ns doc-rev.6116 - Titla 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 i j Nov 17 2016 14:59 Jim The Inspector Man 5085349919 page 7 i . I Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. Cityrrown Slate Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank and two pit's. j Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment: E Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsJpersons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 'I • Nov 17 2016 14:59 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts t Title 5. Official Inspection Form Subsurface Sewage Disposal g p System Form Not for Voluntary Assessments "r 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owners Name information is required for every Osteryille MA 02655 11-14-16 page. Cityfrown State Zip Code Date or Inspection D. System Information (cont.) Last date of occupancy/use: i Date l Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as-part of the inspection? ❑ Yes ® No If.yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: r ® Septic tank, soil a.bsorption 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): 15ins.doc•rev 6/16 Title 5 official Irspection Form:Subsurface Sewage❑isposal System•Page 5 of 17 i i Nov 17. 2016 15:00 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `Y 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos _ Owner Owner's Name information is requiretl for every osterville MA 02655 11-14-16 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: i 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.): Pipeing is , inlet line 6"cast iron outlet 4" PVC SCH 40. Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: i years Is age confirmed by a Certificate of Compliance? (attach a copy,of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal, Precast H-10 Sludge depth: t5ins.doc-ray.6r16 Title 5 Official Inspection Form.Subsurface sewage Disposal System-Page 9 of 17 Nov 17 2016 15:00 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 39 Tower Hill Road(BLOG3) Property Address Village Square South Condos j Owner Owner's Name information is required for every Osterville MA, 02655 11-W16 page. CftylTown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 8' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1 How were dimensions determined? Asbuilt-TapeSludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level, outlet cover steel at grade in grass. Inlet cover under brick walk. Inlet and outlet tees. No sign of leakage or over loading. i 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' k Distance from bottom of scum to-bottom of outlet tee or baffle Date of last pumping: Date 15ins.doc•ev.6116 > Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Nov 17 2016 15:00 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16. page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) i 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? El Yes ❑ No ISins.doc•rev 6/16 _ - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 or 17 Nov 17 2016 15:01 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos _ Owner Ownees Name information is Ostervllle MA . 02655 11-14-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NO BOX 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.): I 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.doc-rev.6116 .. -- • Title 5 Official Inspenlion Form:Subsurface Sewage Disposal System•Page 12 of 17 Nov 17 2016 15:01 Jim The Inspector Man 508534§919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form '4 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name information is Osterville MA '02655 11-14-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: • 2 ® leaching pits number: ❑ leaching chambers number: d ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,-signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two H-20 precasts pits in black top parking area. W/steel cover's at grade. Pit#.1 at 28" below grade 5'water in pit. Pit#2 at 35"below grade dry. 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 15im.doc•rev.6116 _ Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 3 o(17 Nov ,17 2016 15:01 'Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts w Title 5 Official Ins ection Form p Subsurface Sewage Dis osal S stem Form N g p y o of for Voluntary Assessments 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: I. ' Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, ,condition of vegetation, etc.): t , i isins.acc rev..6116 Title 5 Official Inspection Form:Subsurlaos Sewage Disposal system-Page 14 of 17 l Nov 17 2016 15:01 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road(BLDG3) Properly Address Village Square South Condos Owner Owners Name information required for every Osterville MA 02655 11-14.-16 page. CitylTown 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 i 13 /+ -g 13-3 GWR .4 4� ' a 3 t5ins.doc-rev.8116 Title 5 Of tidal Inspection Form:Subsurface Sewage Disposal S7s-.em-Page 1s of 17 Nov 17 2016 15:02 Jim The Inspector Man 5085349919 i page 16 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page, Cityrrdwn State Zip Code Date of Inspection D. System Information (cont_) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar, I ❑ Shallow wells aN� Estimated depth t high ground water: 13'-6" 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: 8-3-10 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.8-3-10 on site, no G.-W. at 1IT-T. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15ins.doo•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Nov 17 2016 15:02 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road(BLDG3) Property Address Village Square South Condos Owner Owner's Name informat required is Ostervllle MA 02655 11-14-16 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r , r r t5ins.doc•rev.6116 - Title 5 Official Inspect on Form:Subsurface Sewage Disposal System-Page 17 of 17 L Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owners Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A Genera! Information filling out forms 1 OFuprp���� on the computer, G o�`0. .. . M,gSS'/y use only the tab 1. Inspector. U S '��o= •', 9° key to move your �: JAMES m= cursor-do not James D. Sears =o; QPAOCZ - use key the return Name of Inspector Capewide Enterprises,LLC %';• cFpT,���° o���� Company Name s'�i � —G'' 153 Commercial St: ����q mn nun `���``• Company Address few Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority d—� 9-5-13 ,oKspectors 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. z�r t5ins•3/13 Tide TMnspection Forth:Subsurface Sawa ge spsal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. CityJrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ahveys 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: 13) 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•3A 3 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name Information is required for every Osterville MA 02655 9-5-13 page. Cityrrown 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(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurtace Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a.surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool E ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth incem"el Is less than 6"below invert or available volume is less than%day flow A17 t5ins•3/13 Tdte.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. cityl-row State Zip Code Date of Inspection B. Certification (cont.) Yes No P ❑ ® 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. ❑ Z 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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. tsins•3113 TOO s Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is Osteryille MA 02655 9-5-13 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? H® ❑ as the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880 t,irre-3113 Tito 5 orfiad Irrspectian Form:Subsurface Sewage Disposer System•Page 6 OF 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.tank and two pit's. Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gpd))� Detail: Sump pump? Yes ® No Last date of occupancy: Present Date Commercialfindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pege 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owners Name information a Osterville MA 02655 9-5-13 required for every page. cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Daft Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface nspedio Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/-Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes [D No Building Sewer(locate on site plan): Depth below grade: 2 11 feet Material of construction: ®cast.iron [D 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,inlet line 6"cast iron, outlet 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast Sludge depth: 211 t5ins•3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information required for every Osterville MA 02655 9-5-13 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 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level, outlet cover steel at grade in grass area,inlet cover under brick walk Inlet and oulet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: ` Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons peg 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 I t5ins•3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 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 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.): 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 Tine 5 Office]Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owners Name information is required for every Osterviile MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative 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 two H-20 precasts pits,in black top parking area W/steel cover's at grade. Pit#1 at 28" below grade,5'water in pit. Pit#2 at 35"below grade,dry ,no sign of over loading. 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•3113 Tide 5 of oal In spacdon Form:Subsurrace Sewage Disposal System•Page 13 of 17 . l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Trtb 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `< 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately e O3 t5ins•3113 Title 5 Official ins pection Form:Subsurface Sewage Disposal System•Page 15 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 39 Tower Hill Rd. BLDG. 3 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells d 13'-61' Estimated depth t high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8-3-10 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. 8-3-10 on site, No G.W. at 13'-6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsins•3113 Title 5 Oftal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 3 ' Property Address Village Square South Condos Owner Owners Name information is required for every Osterville MA 02655 9-5-13 page. Citylrown 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•313 Me 5 official Insp ection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 205&215 Pine Lane Extension(Bldg 3&4) // 7 ''64�v" b Y Osterville, MA 02655 Owner's Name: C/o First/Property Manatrement 2� Owner's,Address: Osterville Commons Date of Inspection: Aultust 10, 2006 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 r CERTIFICATION STATEMENT 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 N e s Further Evaluation by the Local Approving Authority F I Inspector's Signature: Date: August 15, 2006 The system inspector shall subi14copy 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. Notes and Comments - ****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. Title 5 Inspection Form 6M/2000 page 1 i Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205&215 Pine Lane Ext. Osterville, MA Owner: First Property Management Date of Inspection: August 10, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Sys Conditionally tonally 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is'removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205&215 Pine Lane Ext. Osterville, MA Owner: First Property Managgenient Date of Inspection: August 10, 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine 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 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance "This system passes if the well water analysis,performed at a.DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of anunonia 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205&215 Pine Lane Ext. Osterville MA Owner: First Property Management Date of Inspection: August 10, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/z day flow ✓ Required pumping more than 4 times in the last yea r NOT due to clogged or obstructed ptpe(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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system the system'must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 205 do 215 Pine Lane Ext. Osterville. MA Owner: First Property Management Date of Inspection: August 10, 2006 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: Yes No ✓ _ 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(3)(b)]. 5 'I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 205&215 Pine Lane Ext. Osterville. MA Owner: First Property Management Date of Inspection: .August 10. 2006 FLOW CONDITIONS RESIDENTIAL 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): N1a Number of current residents: n1a Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping.Records Source of information: Pumped yearly for maintenance Was system pumped as part of the inspection(yes or no): . 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of infornation: ITastalled on 12131196-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 205&215 Pine Lane Ext. Osterville. MA Owner: First Property Management Date of Inspection: August 10, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: —cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12"&40" Material of construction: ✓ concrete _metal —fiberglass _polyethylene ex —other(explain) n) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2- 1500 a� 1. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: 205&215 Pine Lane Ext Osterville. MA Owner: First Property Manazement Date of Inspection: August 10, 2006 TIGHT or HOLDING TANK: None (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: allons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no)` ' Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened) locate on site la p )( 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.): No solids were present PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) , Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205&215 Pine Lane Ext. Osterville, MA Owner: First Property Manavement Date of Inspection: August 10, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: ✓ leaching galleries,number: 18 galleys-per plans leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Continents (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): The ealleys were not dug up. There were no signs of failure in D-box CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Cominents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 205&215 Pine Lane Ext. Osterville, MA Owner: First Property Management Date of Inspection: August 10, 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Iles as r r , t a( 30 �6 � r a�. ,.,r Li a 10 a � Page I 1 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205&215 Pine Lane Ext. Osterville. MA Owner: First Property Management Date of Inspection: August 10, 2606 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showinypyroximately 25'+1-to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 � tq-9 r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P OT ED AUG 2 8 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE S OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 205&215 Pine Lane Extension(Bldg. 3&4) Osterville, MA 02655 Owner's Name: Osterville Commons Owner's Address: c%First Property Management 832 Main Street, Osterville, MA 02655 Date of Inspection: July 23, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 117 Mailing Address: P.O. Box 49 Parcel. 075 Osterpille,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT 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 N urther Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: August 10, 2003 The system inspector shall subm 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205&215 Pine Lane Extension, B1dQ. 3&9 Osterville,AM Owner: Osterville Commons Date of Inspection: July 23, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, AM Owner: Osterville Commons Date of Inspection: July 23, 2003 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: I 3 Page 4 of 11 e OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, MA Owner: Osterville Commons Date of Inspection: July 23, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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 ''/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 well.- Any portion of a cesspool or privy is within 50 feet of 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 I0d- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 205&215 Pine Lane Extension, B1dQ. 3&4 Osterville, M4 Owner: Osterville Commons Date of Inspection: July 23, 2003 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, AM Owner: Osterville Commons Date of]inspection: July 23, 2003 FLOW CONDITIONS RESIDENTIAL 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): n/a Number of current residents: Unknown Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): -No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped yearly for maintenance-per manager Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: eallons--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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Dec. 31196-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, MA Owner: Osterville Commons Date of Inspection: July 23, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2- 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" 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: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was up to the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, AM Owner: Osterville Commons Date of Inspection: July 23, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.): The D-box was level. No solids were present. Recommend installing risers on the D-box. The cover was Y below grade PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, AM Owner: Osterville Commons Date of Inspection: July 23, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: ✓ leaching galleries,number: 18 galleys-per plans 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.): The Qalleys were not dun;up. There were no signs offailure in the D-box. The bottom to trade was approximately 7'. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 205&215 Pine Lane Extension, B1dQ. 3&4 Osterville, AM Owner: Osterville Commons Date of Inspection: July 23, 2003 Map: 117 Parcel: 075 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. � a1� ate 34 30 1b a0r /3A4k awe. y v+►�' 1 ► 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 205&215 Pine Lane Extension, Bldg. 3&4 Osterville, AM Owner: Osterville Commons Date of Inspection: July 23, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You mast describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 25'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 I f Commonwealth of Massachusetts Title 5 Official Inspection Form - o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG.4 t Property Address .__. J6 Village Square South Condos Owner owner's Name information required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. ImporUrdfling out forms A. General Information filling out forms ``����� OF qs on the computer, `000 ......... SqC' use only the tab 1. Inspector. key to move your a 0 cursor-do not James D. Sears , =o: J A M E S use d SEARS key.the return Name of Inspector * ; Capewide Enterprises,LLC V'•• Company Name I N Sp 153 Commercial St. ��unnIIII"1 \0 Company Address ram, Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9 9-5-13 spectofs Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 offi 'on Form:Subsiufaoe Sewage Disposal System•Page 1 or 17 Commonwealth of Massachusetts ffl�ff Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired..The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t51ns•3/13 Title 5 Olfiaal hspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments now 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. S) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Offidel Inspection Form:SubsuAace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG.4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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 amppW is less than 6"below invert or available volume is less than %day flow t5ins-313 Title 5 Official Inspection Forth:Subsiatace Selvage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y( 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) barge Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system Y r9 has fail y s ed.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-3113 Title 5 Official trtspedion Form:Subsurface Sewage Oisposel System•Page 5 0117 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 39 Tower Hill Rd. BLDG.4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 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 ❑ . 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 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): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880 Mina-3113 Me 5 Offidal inspection Form:Submsface Sewage Disposal System-Page 6 of 17 l _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 2000 Gal. tank and two pits. Number of current residents: NA 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 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y g (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 7 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °e 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, dMONEgm 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•3A3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 IN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG.4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): Depth below grade: 28"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,inlet line 6"cast iron,outlet 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast Sludge depth: 2" t5ins•3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Pepe 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" 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 17" -Tape u How were dimensions determined? Asbilt Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level,w/Both covers steel at grade in grass area, Inlet and oulet tees. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3H 3 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons peg 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•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG.4 Property Address Village Square South Condos Owner Owner's Name lug information required for every Cisterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): 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: t5lns•3113 Trite s 011dal In spection Fan Subsurtace Sewage Disposal System•Page 12 of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precasts pits, W/steel cover's at grade. Pit#1 Full.. Pit#2 1' water. Both pits are 9'deep. No sign of over loading or solid carry over. Note: pit#2 is piped from pit#1 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•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 9-5-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•3/13 Title 5 Offiaaf Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 , 57 0 0 o °O O � 3 f t5irm•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N° Estimated depth tcrhigh ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,date of design plan reviewed: 8-3-10 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. 8-3-10 on site, No G.W.-at 13'-6". Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspsaion form:SubsuAaoe Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments s� 39 Tower Hill Rd. BLDG. 4 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ` ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pap 17 of 17 : Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Wily- 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 9-5-13 required for every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:when A. Genera! Information filling out forms OF on the computer, \��������`�.• SSyc�,,�, use only the tab key to move your 1. Inspector: y� `��� • JAMES • yN' cursor-do not James D. Sears �J =o i - use the return _ ; SEARS :9 key. Name of Inspector Capewide Enterprises,LLC s��• cFRriF����,� y---w Company Name •i N.SP \`\`�, 153 Commercial St. "'"till lllllIII0\0 Company Address Mashpee MA 02649 Cityfrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-5-13 ,golfs 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. 3 t5ins•3113 Title 5 official Inspection nffnul Sewage Disposal System•Page t of 17 J t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner Owners Name information required for every Osterville MA 02655 9-5-13 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: 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", "non 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 exltration 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-3113 Title 5 Official Inspection Fomr.Subsurface nspedi Sewage Disposal System•Page 2 of 17 l - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Flame information is required for every Osterville MA 02655 9-5-13 page. Cityrrown 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): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Offoal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5 U Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 lug 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 is less than 6"below invert or available volume is less than Y2 day flow ovi s t5ms•3113 Title 5 official trrspeciion Form:Subsurface Sewage Disposal System•Pege 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner Owner's Name information required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high.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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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 P PP Y 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 Titt 5 Official krepection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner owner's Name information required for every Osterville MA 02655 9-5-13 page. City/rown 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 Z ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): NA DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA t5ins-3H3 rft 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5 M Property Address Village Square South Condos Owner Owner's Name information required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspedion D. System Information Description: The system is a 2000 Gal.tank D Box and two pits. Number of current residents: NA 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 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP )k Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tsins•3113 Title 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts leiTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 9-5-13 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 official tnspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner owner's Name information required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 Building Sewer(locate on site plan): Depth below grade: 30"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,inlet line 6"cast iron,outlet 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal. Precast Sludge depth: 3" t5ins•W3 Title 5 offidel inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown 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 2!" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level,w/Both covers steel at grade in grass area, Inlet and oulet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3r13 Title 5 Offidel In spection Form:Subaurfaoe Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments on pumping recommendations inlet and outlet tee or baffle condition, ( P P 9structural integrity, liquid levels as related to outlet invert evidence of leakage,a, etc. :9 ) 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Name information required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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.): a t5ins•3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachu setts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. ® hand-sketch in the area below ❑ drawing attached separately -J = ,27 13—/ _; o 19 3 - Mo I s�� o ® 0 O L14 OOM s t5ins•3113 Title 5 offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water - ❑ Check cellar ❑ Shallow wells N 13'-6" Estimated depth t high 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., 8-3-10Date ❑ 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. 8-3-10 on site, No G.W. at 13'-6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Dis posal sposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown 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 16"x16-30"Below grade w/cover steel at grade. Box is clean and solid w/two 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-3113 Title 6 Official inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 39 Tower Hill Rd. BLDG. 5 W Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. CityMown State Zip Code Date of inspection D. System Information (cont.) 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 Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precasts pits, Pit# 1 at 3'below grade w/cement cover at grade 2'water in pit. Pit#2 at 4' below grade w/30"water. No sign in pits 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 t5ins-3113 Title 5 Offfdel Forth:Subsurface inspection Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. BLDG. 5&6 Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information 221 formp the com utoter,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name tIlIQ P.O.Box 763 Company Address Centerville Ma. 02632 reran City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: } ® Passes ❑ Conditionally Passes ❑ Fails o O ❑ Needs Further Evaluation by the Local Approving Authority c z � o =n 7/20/2010 Inspe or's Signature Date 3 Z Cl) The system inspector shall submit a copy of this inspection report to the Approving Attrfhord�(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shl seem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shag@ubrfirf4 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. LV l/ t5ins-09/08 Title 5 Official Inspection Form:Subsurface p s ace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Units 3,4B,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Units 3,4B,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The ❑ Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 39 Tower Hill Rd. (Units 3,4B,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 39 Tower Hill Rd. (Units 3,413,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ElWas 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): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information . Description: Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7/20/2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal list age:ge: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 2" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,4B,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box if present must be opened locate on site plan): Depth of liquid level above outlet invert No D-Box present. 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pit#1 was full to invert at time of inspection.Pit#2 was dry.Stain line observed 5' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 39 Tower Hill Rd. (Units 3,413,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i j Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. (Units 3,413,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every 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 a f1 3 ,3 a .S7 a s 3 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 39 Tower Hill Rd. (Units 3,413,4D) Property Address Village Square South Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 28' 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: As-built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Tower Hill Rd. (Units 3,46,4D) Property Address Village Square South Owner Owner's Name information is required for Osteryille Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI=R�S�rt� 1B? DEPARTMENT OF ENVIRONMENTAL PROTE iffild'k 28 AH 9:�54 uirvlsla TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Units 3, 4B and 4D(Septic System #1) Property Address: 39 Tower Hill Road Osterville. MA 02655 Owner's Name: Village Square South Condominium Association Owner's Address: P.O. Box 598 Osterville, MA 02655 Date of Inspection: June 11, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT 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 inaintenance 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: % Date: June 13, 2005 The system inspector shall sub 't 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. Notes and Comments ""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. Title 5 Inspection Form 6/15/2000 page 1 L_ S Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 3. 4B and 4D)--Svstem#1 Osterville. MA Owner: Village Sguare South Condominium Association Date of Inspection: June 11, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated.are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 L Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 3. 4B and 4D)-Sysiem#1 _ Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 3. 4B and 4D)--System#1 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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''/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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department: 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Tower Hill Road(Units 3, 4B and 4D)-System#1 Osterville. MA Owner: Village Sguare South Condominium Association Date of Inspection: June 11, 2005 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Tower Hill Road(Units 3. 4B and 4D)-System#1 Osterville• MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 6 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n1a Number of current residents: n1a Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Some units Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAVINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped yearly for maintenance-Pumped approx. 6 weeks ag_o for maintenance Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approximately 1972-per design plans Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 3. 4B and 4D)-Svstem#1 Osterville. MA Owner: Village Square South Condominium:Association Date of Inspection: June 11, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grader 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 30 Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be anv signs of leakage. The steel covers were to grade. The tank was pumped for maintenance approximately 6 weeks ago GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 3 4B and 4D)-Svstem#1 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: None' (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 3 4B and 4D)-System#1 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: _ 2-6'x 6'with 3.5'stone-per design plans leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc:): One nit 02) had approximately 5'of liquid on the bottom The other pit#3 was drv. There did not appear to be any signs of failure. All steel covers were to grade. The bottom to grade was 10' CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road(Units 3 4B and 4D)-System#1 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. 2 � 1 a A 3 3 aS7cs 3 ?aYI 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 3. 4B and 4D)-Svstem#1 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 43 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the snaps were showing approximately 43'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500' ` c f TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART A, r h - CERTIFICATION- Septic System#1 Property Address: 39 Tower Full Road, Osterville, MA Name of Owner: tillage Square South Condominium Association Units 3, 4B&4D Address of Owner:' P-O. Box 598, Osterville, MA 02655 Date of Inspection: March 1, 1999 p Name of Inspector: (Please Print) lames M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: lames M. Ford Mailing Address: P.O. Box 49, Osterville, MA 026SS-0049. Map: 117 Telephone Number: (S08)862-9400 i , 072 Parcel: CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system ✓ Passes { Conditionally Passes Needs Further Eval ion By the Local Approving Authority Fails _ t Inspector's Signature: . Date: March 7, 1999 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority NOTES AND COMMENTS t R ti O APR. . LL 9 1999 E 9 CA revised 9/2/98 Page Iof11 Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA (Units 3, 4B&4D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as roved by the Board of Health, will pass. comp rep � approved Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,.whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required.pumping more than four 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 obstruction is removed revised 9/2/98 Page 2of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) y ' Property Address: 39 Tower Hill Road, Osterville, MA (Units 3, 4B&4D) ; Owner: Village Square South Condominium Association x; Date of Inspection: March 1, 1999 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 the public health, safety and 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 THE PUBLIC HEALTH"AND 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: 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is,within"100.feet to a surface water supply,or tributary to a surface water supply. , The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption`system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil"absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of amnia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA (Units 3, 4B&4D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 D. SYSTEM FAILS: You trust indicate either "Yes" or "No" as to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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'/x 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for colifotm bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 trapped Zone II of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL° SYSTEM INSPECTION FORM PART B CHECKLIST t Property Address: 39 Tower Hill Road, Osterville,'MA (Units 3, 4B&4D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 F = Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumpedfor at least two`weeks and the system has;been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this { inspection. ✓ As built plans have been obtained and examined. Note if they are not available with NIA: ✓ _ The facility or dwelling-,was inspected for signs of sewage back-up. ✓ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout.:. ✓ _ All system components, excluding the Soil Absorption System,have been located on the site.,. g` ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspectedfor conditions of baffles rt or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.' The size and location of the Soil Absorption System on the site has been determined based on. ✓ _ Existing information. For example, Plan at B.O.H: ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation'of distance is unacceptable) [15.302(3)(b)1• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. - - •' _ _ � w y ;'�''-- • a • x , •'fit:. ,- c .. z-._,y, .. .. , revised, 9/2198 Page 5'oflf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION . Property Address: 39 Tower Hill Road, Osterville, MA (Units 3, 4B&4D) Owner: Village Square South Condomdnium Association Date of Inspection: March 1, 1999 FLOW CONDITIONS - RESIDENTIAL: Design flow: — P .d./bedroom. g Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow Number of current residents: _ Garbage grinder(yes or no): Laundry(separate system)(yes or no): _; If yes, separate inspection required Laundry system inspected(yes or no): _ Seasonal use(yes or no): Water meter readings, if available(last two yearg;usage(gpd): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Residential Condominiums Design flow: 600 gpd(Based on 15.203) Basis of design flow SO gN per person-2 persons per bedroom Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system (yes or no) No Water meter readings,if available: 1998-134,000 gals.; 1997-103,000 gals. Last date of occupancy: Currently occupied. OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped once per year for maintenance-per Manager. System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 1972-per design plans Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL' SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road,,Osterville, MA (Units 3, 4B&4D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 ' BUILDING SEWER: , (Locate on site plan) ' Depth below grade: Material of construction: _cast iron _40 PVC other(explain) t_ Distance from private water supply well or suction line Diameter Conurients: (condition of joints, venting,evidence of leakage,etc.) SEPTIC TANK ✓ . (locate on site plan) , Depth below grade: Covers to grade Material of construction: ✓concrete _metal _Fiberglass Polyethylene =other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance, (Yes/No) ' Dimensions: 10'6'x 5'6" x 5'6' (1500 gal.) . . .. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle:' ".32' Scum thickness: 4' _ .f 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: 8" How dimensions were determined: Measuring stick .. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level,in relation to outlet invert, structural integrity, evidence of leakage,etc.) The tees were present The liquid level wds even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: - W 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: -- ---_ _ - - Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) - revised 9/2/98 Page 7of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION•FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road, Oslerville, MA (Units 3, 4B& 4D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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/day Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: No box found. (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) " Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8oflI �I SUBSURFACE SEWAGE `DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA'(Units`3,•4B& 4D) Owner: Village Square South Condominium Association ' Date of Inspection: March 1, 1999 - « SOIL ABSORPTION SYSTEM (SAS): ✓ + (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: 4 r Type: leaching pits,number: 2 leaching chambers, number: leaching galleries,number: - leaching trenches,number,length: a leaching fields,number,dimensions: „ overflow cesspool,number: k Alternative system Name of Technology: Comments: .. r (note condition of soil, signs of hydraulic failure,level of ponding,"damp soil, condition of vegetation,etc.)'The leaching pits were 6'x 6'with 31/2' of stone per the design plans. The bottom to grade was 10' There were no signs of failure - CESSPOOLS: None (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(cesspool must be pumped as part of inspection) + - Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc:) - PRIVY: None , (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.), . revised 9/2/98 t Page 9ofIV SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road, Osterville, MA (Units 3, 4B&4D) Owner: Village Square South Condominium Association Date of Inspection: March 1, 1999 Map: 117 Parcel. 072 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I Dooe. �y 3,D. Un t i 3 m 0 I revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)' Property Address: 39 Tower Hill Road, Osterville, MA (Units 3; 4B&4D) Owner: Village Square South Condominium•Association Date of Inspection: March 1, 1999 NRCS Report name r Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep' SITE EXAM Slope Surface water ' Check Cellar Shallow wells ' Estimated Depth to Groundwater Feet ;. ... Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement-sump etc.); Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Using the Barnstable water table and topographic maps, the maps were showing approximately 43'-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection: This report is not a.warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system,-the inspection and/or this report. �. revised 9/2/98 Page 11 of 11 Commonwealth of Massachusetts 07- -2-00A- Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 39 Tower Hill Road (BLDG 4-A-C 5-A-C) t� Property Address Village Sguare South Condos a Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. Cityrrown State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. ulltt ttply71i Important;when ng filling out forms A. Inspector Information 54 j 38 s on the computer, g� JA M E S N use only the tab James D.Sears o` ; key to move your Name of inspector g j 6EAR cursor-do not Capewide Enterprises use the return — 1r. a a key. Company Name ' te •. RTt���O\�. 153 Commercial Street ,,�s INspE �� Q Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system; 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11-5-19 spec or'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. tSinsp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 a5ed xed dH U00 61,02 90 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F, 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 2000 Gal. Tank and two pits. 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): t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 5 a5ed xed dH 86:00 61,0Z 90 AON Commonwealth of Massachusetts 6z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name Information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): . ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (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 CHAR 15,303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16 9 abed Xed dH 2 6:00 6 60Z g0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name formation is every Osterville squired for MA 02655 11-4-19 page. city(fown State Zip Code Date of Inspection C. Inspection Summary (cost.) ❑ 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 coftform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, 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: v 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 or 18 a5ed xeJ dH 86:00 61,0e 90 AcN Commonwealth of Massachusetts Title 5 Official Inspection Form �S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owners Name information is required for every Osterville MA 02655 11-4-19 Pap. City7own 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 anoMmr is less than 6"below invert or available volume is less than'/:day flow 09ir,.r ❑ ® Required,pumping more than 4 times in the last year NOTdue 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 0.4. 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 publlc water supply well t5insp.doc-rev.7h2812018 Title 5 Official Inspection Form:Subsurface savage Disposal System•Page 5 of 18 g a5ed xed dH 8 6:00 6 60E g0 AON Commonwealth of Massachusetts, Title 5 Official Inspection Form jF Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C,5-A-C) Property Address Village Sguare South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. Cityrrown State Zip Code Date of Inspectlon 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: r 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? E] ® 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. 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)] t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 18 6 a6ed xeJ dH 2 6:00 6 60Z 90 AoN Commonwealth of Massachusetts k ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments viw9i 39 Tower Hill Road BLDG 4-A-C 6-A-C Property Address Village Square South Condos Owner Owner's Name Information is required for every Osterville MA 02655 11-4-19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 Description: 2000 Gal.Tank and two pits. Number of current residents: NA 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t51n5p.d0c•rev.7/26/2018 Title 5 Official Inspectim Form:subsurface Sewage Disposal System•Page 7 of 18 p abed xed dH 6 6:00 6 60Z g0 AoN °y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name equiretlonIs r d for every Osterville MA 02655 11-4-19 require page. CitylTown 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/personsisq.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 occupancyluse: Date Other(describe below): 3. Pumping Records: Source of information: yearly pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5lnsp.doc rev.n2emiB Tide 5 Official Inspection Form:Subsurface Sewage 01sposal system•Page s of to t t a5ed YU dH 6 1,:00 61.OZ 90 AcN Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name Information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy - - ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet i Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing - inlet line 6°cast iron w/outlet 4" PVC SCH -40 t6insp.doc-rev,7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 or 19 r Z a5ed xe� dH 61•:00 61,0Z 00 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vI 39 Tower Hill Road (BLDG 4-A-C 5 A-C) Property Address Village Sguare South Condos Owner Owner's Name Information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): 1611 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal. Precast Sludge depth: T. Distance from top of sludge to bottom of outlet tee or baffle 2911 Scum thickness 1" 12" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): Tank at working level w/both covers steel at grade in grass area. Inlet and outlet tee's. No sign of leakage or over loading. t6insp.doc rev.7126/201S Title 5 Official Inspectan Farm:Subsurface Sewage Disposal System•page 10 of 19 £6 a6ed YPJ dH 02:00 660Z 90 ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owners Name information is required for every Ostervllle MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): i 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 SOfficial Inspection Form:Subsurface Sewage Disposal system-Page 11 of 18 b abed YU dH 02:00 61,2 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) 8. Tight or Holding Tank(cont,) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Box 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.): Wrisp.doc•rev.7l26=18 Title 5 Offical Inspection Form:Subsurrace Sewage Disposal Syslam-Page 12 of 1e S 6 abed Xed dH OZ:00 6 60Z 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owners Name information is Osterville required for every MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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: 15nsp.doc•rev.7126t2018 TAW 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 91, a5ed xed dH ONO 61.OZ g0 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. Cityfrown 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 two precast pit's piped inline w/steel cover's at grade. Pit#1 Level at outlet. Pit#2 4" water.W/stain line at 2'. Both pits are 9'deep 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.7/26/2018 Title 5 Official Inspectlon Forth:Subsurface Sewage Oispwal System-Page 14 of 18 a5ed xed _dH 2:00 61,OZ g0 AON Commonwealth of Massachusetts VTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,•�y 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Sguare South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page, CitylTown 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.): l5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 g a5ed xed dH WOO 61.0Z 90 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C_ 5-A-C__) Property Address --- Village Square South Condos Owner Owner's Name -- information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building, Check one of the boxes below: ® hand-sketch in the area below ` ❑ drawing attached separately 3�' A r� 8. o � WrraeO•rA 6H8 TAeld6tlolh•p«ae ^,, 6� h[�bIM�00"smam,Pam rsa» b£'d LL6b-L�b-605 sesud,elu3 ep,medeo 61, a6ed xed dH 000 61,OZ 90 AoN Commonwealth of Massachusetts ,z Title 5 Official Inspection Form aaSubsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspectlon D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 13'-6" 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: 8-3-10 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.8-3-10 ,no G.W. at 13'-6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc rev.M612018 Title 5 Official Inspection Forth:subsurface Sewage Disposal System-Page 17 of 18 OZ abed xed dH 2:00 640Z g0 AON t\ Commonwealth of Massachusetts 1-2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �j 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owners Name information Is required for every OStervflle MA 02655 11-4-19 page. City/Town State Zip Code Date of inspection- E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3,or 4 checked ® C. Inspection Summary: 1, 2,3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D.System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included , P/T C 0 t5insp.doc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 lZ abed xeJ dH 000 660Z g0 AON Nov 17 2016 15:02 Jim The Inspector Man 5085349919 page 18 Co f�d mmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (BLD(3 4-A-C 5-A-C) Property Address r-+ Village Square South Condos ' Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection PC •ia 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 il A. General Information 5l* 1-aa3 filling the computer, / ``�` SN OF rA4'tS, use only the tab 1. Inspector: 9�y key to move your ��: JA MES •,S cursor-do not James D.Sears use the return Name of Inspector J rJ: AIRS key. Capewide Enterprises, LLC Company Name !,`c�,�� .�.t.r7—.. 153 Commercial Street pu;NSO- Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority art:-a- 11-14-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc•rev.616 • Title 5 Official Inspection Fount Subsurface Sewage Disposal System•Page 1 of 17 Nov 17 2016 15:03 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. . I 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner 'Owner's Name information is required for every Osterville MA 02655 11=14-16 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D„ A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 2000 Gal. Tank and two pits. 1 i 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 orrepair, 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); 1 t5ins.doc•rev.6116 Title 5 Official Inspection form:Subsurface Sewage Disposal System-.Page 2 of 17 Nov 17 2016 15:03 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 11-14=16 required for every page. City(rown 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 pt$e(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑-ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below)' R , t . 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 l ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh - l5ins.4oc•rev.61.16 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Nov 17 2016 15:03 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Properly Address Village Square South Condos Owner Owner's Name information is required for every Osteryille MA 02555 11-14-16 page. Citylrown 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� n 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 Ei ® 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 N or clogged SAS or cesspool ❑ ® Liquid depth in I is-less than 6" below invert or available volume is less than '/Z day flow P,7 S 15ins.doc•rev.606 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 o1 17 Nov 17 2016 15:04 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form tt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of•the SAS, cesspool or privy is below high,ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a*public well. El ® 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. El ® 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 El i ❑ 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 5 system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.coc•rev.611a Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Nov 17 2016 15:05 Jim The Inspector Man 5086349919 page 23 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address ` Village Square South Condos Owner Owners Name informationis required for every Cisterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection C. Checklist i Check if the following have been done.,You.must indicate"yes' or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the.interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ' ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(5)J D.,System Information Residential Flow Conditions: Number of bedrooms (design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): r 880 i ' t5ins.doc•:rev.6/15 Title 5 Mold Inspection Form;Subsurface Sewage Disposed System•Page 6 at 17 L Nov 17 2016 15:05 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 'The system is a 2000 Gal.Tank and two pits. x . { Number of current residents: NA 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 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Comm ercialllndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ElYes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No x Water meter readings, if available: 15ins.doc-rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Nov 17 2016 15:05 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts r Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road.(BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owners Name information is required for every Osterville MA 02655 11-14-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Data Other(describe below): General Information i Pumping Records: Source of information:. Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping.- Type of System: ® Septic tank, 111111112MIERM 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. El Other(describe): t5ins.doc j rev.6/78 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of W Nov 17 2016 15:06 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts r Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address p Village Square South Condos j Owner Owner's Name information is required for every Ostervllle MA I 02655 11-14-16 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: NA Were sewage odors detected when arriving at the site? ,❑ Yes ® No Building Sewer(locate on site plan): 2811 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 inlet line 6"cast iron, outlet 4" PVC! SCH 40. Septic Tank(locate on site plan): 16" 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 i 2000 Gal. Precast Dimensions.-. Sludge depth: t5lns:doc rev.6116. - Title 5 Official Inspection Form:Suhsurace Sewage Disposal System-Page 9 of 17 f Nov 17 2016 15:06 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts I Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name required on is osterville MA 02655 11-14-16 required for every page. City/town State .Zip Code Date of Inspection D. System Information (cont.) C Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness Distance from top of scum to top of outlet tee or baffle 12" 17 Distance from bottom of scum to bottom of outlet tee or baffle 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.): Tank at working level w/both covers steel at grade in grass area. Inlet and outlet tee's. No sign of leakage or over loading. i I 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 15 m.Coc+rev.8116 I Title 5 Dffdal Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Nov 17 2016 15:06 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA{ 02655 11-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): r 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): i 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 r 151ns.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Nov 17 2016 15:07 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 ' 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is Osterville MA 02655 11-14-16 required'for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan):. Depth of liquid level above outlet invert No Box 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes s ❑ 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: P f5im.doc•rev.6116 Title 5 Official I-ispectlon Form:Subsurface Sewage Disposal System•Page 12 of 17 Nov 17 2016 15:07 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm -Not for Voluntary Assessments . 39 Tower Hill Road(BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every osterville MA 02655 11-14-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two preacast pit's wlsteel cover's at grade. Pit# 1 Level at outlet.Pit#2 2'.water. Both pits are 9'deep. No sign of over loading or solid carryover. y 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.doc•rev.6116 I Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Nov 17 2016 15:07 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C). Property Address Village Square South Condos Owner Owner's Name - information is required for every Cisterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ' ' 9 t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 Nov 17 2016 15:08 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. City/Town Stale Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a iew 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 177 3 o o t y41� U t51ns.doc-rev.6/16 Title 5 Official Inspection Fom:Subsurface Sewage Disposal System•Page 15 of 17 Nov 17 2016 15:08 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary. Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) ' Property Address Village Square South Condos Owner Owner's Name ' information is required for every Osterville MA 02655 11-14-16 page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) f Site Exam: i ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells, Estimated depth to high ground water: 13'-6" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 8-3-10 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. 8-3-10 on site, no G.W. at 13'-6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-doc_-rev.6/16 - Title 5 Official Inspoction Form:Subsurface Sewage Disposal System•Page 16 of 17. Nov 17 2016 15:08 Jim The Inspector Man 5085349919 j page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 4-A-C 5-A-C) Property Address Village Square South Condos Owner Owner's Name information is required for every OstefVille MA 02655 11-14-16 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 p 9 9 . ® Sketch of Sewage.Disposal System either drawn on page 15 or attached in separate file I 1 rev.6116 , . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osteryille Ma. 02655 7/20/2010 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: A. General Information When filling out forms on the computer,use 1. Inspector: V/l/ only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name VS-6ji P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: c —+1 ® Passes ❑ Conditionally Passes El c ' c,) O ❑ Needs Further Evaluation by the Local Approving Authority ^ 7/20/2010 3 co Insp ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving A4-horig(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shalom 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. /I b t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal S tem•Page 1 of 1 I __ Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septis system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osteryllle Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is Osterville Ma. 02655 7/20/2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No Pumping information was provided b the owner, occupant, or Board of Health ® ❑ P 9 P Y � P ❑ ® 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? El 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): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7/20/2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth-of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010_ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal list age:g years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gallon Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I� i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 40" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6„ Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons - Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No D-Box present. 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 l r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pit#1 was full to invert.Pit#2 had 2' of water on bottom.Stain line observed 50" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts 9.3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every 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 Dorf A� A,C Moor . O O A a a' a� -rA,%k exm Cr t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 l� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 26' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. (Unit 4A,4C,5A,5C) Property Address Village square South Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS [0��'tl IfF SgAR�4S,TA L�"s' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTb&1dN28 AN 9: 54 . TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Units 4A, 4C, 5A&5C(Septic System#2) Property Address: 39 Tower Hill Road Osterville. MA 02655 v Owner's Name: Village Square South Condominium Association Owner's Address: P.O. Box 598 Osterville, MA 02655 Date of Inspection: June 11, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 13, 2005 The system inspector shall su4 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. Notes and Comments- ****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. Title 5 Inspection Form 6/15/2000 page 1 I t Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 4A, 4C. 5A& 50-System#2 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not detenmined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 4A, 4C, 5A &50-System#2 Osterville, MA Owner: Village Sguare South Condominium Association Date of Inspection: June 11, 2005 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 j 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 L I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 4A. 4C, 5A &50-Svstem#2 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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'h 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Tower Hill Road(Units 4.4, 4C. 5A &50-Svstem#2 Osterville. MA Owner: Village Square South Condom iniuin Association Date of Inspection: June 11, 2005 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: Yes No 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(3)(b)]. 5 I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Tower Hill Road(Units 4A, 4C, 5A&50-System#2 Osterville, MA Owner: Village Sguare South Condominium Association Date of Inspection: June 11, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: n/a Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Some units Water meter readings, if available(last 2 years usage(gpd)): Unavailable. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): J GENERAL INFORMATION Pumping Records Source of information: Pumped yearly for maintenance-Pumped approx. 6 weeks ago for maintenance Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approximately 1972-per design plans Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 4A, 4C, SA&50--System#2 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Covers to grade Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2000 gal. (10'6"x 6'8"x 5') Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 44" Scum thickness: /" Distance from top of scum to top of.outlet tee or baffle: 9 Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. The steel covers were to grade. The tank was pumped for maintenance approximately 6 weeks ago. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road(Units 4A, 4C. 5A&SC)-System#2 Osterville, MA Owner: Village Sguare South Condominium Association Date of Inspection: June 11 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 4A. 4C. SA&SC)-Sy stem#2 Osterville MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2 -9'x 6'with 5'stone(per design plans) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): One pit 01)was full. The other pit 02)had 2'ofliguid on the bottom. There did not appear to be an signs i,gns offailure Steel CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 4A. 4C. 5A&50-System#2 Osterville,MA .... . - — --...... ..__._ ...._ _.. Owner: Village Sguare South Condominium Association Date of Inspection: June 11, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Door ABC ,� A,C- Moor A 3 0 0 A a ' a 3s' 'TAnk WCr 54 a� -T-4„k cvncr ya' 1 I SI S,� PIT 10 L 7 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 4A, 4C. 5A&50-System#2 Osterville, MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 43 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 43'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied,relating to the system, the inspection and/or this report. 11 I Nov 06 2019 00:21 HP Fax page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , v 39 Tower Hill Road(BLDG 5-B-D &6-7-B-9) Property Address ' Village Square South Condos r. Owner Owner's Name information reqequiredcredforr every Osterville MA . 02655 11-4-19 e , 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. `1%1111uu F Hu4/77/i Important:When filling out forms A. Inspector Information �51*/1-/a 3q on the computer, ?g;' JAMES G use only the tab James D.Sears key to move your Name of Inspector = r cn cursor-do not _*•' use the return Companyp Na enterprises y� �t�'rr`�`' F key, �F 5 i N S4EG``\��� 153 Commercial Street y�� rrff�pt„ Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further.Evaluation by the Local Approving Authority 4. ❑ Fails 11-5-19 pector'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.712W O18 Title 5 OfBcW Inspecfion Form:Subsurface Sewage Disposal System•Page 7 of 18 Nov 06 2019 00:21 HP Fax page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-D & 6-7-8-9) Property Address Village Square South Condos Owner Owners Name information is required for every psterville MA 02655 11-4-19 page. CityJown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 2000 Gal Tank D Box and two pit's i 2) System Condidonally 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): 151nsp.doc-rev.N26l2018 TOe 5 Official Inspection Form:subsLeace sewage asposal system-Page 2 of 18 Nov 06 2019 00:21 HP Fax page 24 y Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos Owner owner's Name information is required for every Osterville MA 02665 11-4-19 paw. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cost.): ❑ 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): ❑1 broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (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.7126f2018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal system•Page 3 or 18 i Nov 06 2019 00:22 HP Fax page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-D&6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information o r e Osterville MA 02655 11-4-19 required for every per. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) ❑ 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 tNnsp.doc rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Olsposal System-Page 4 of 18 Nov 06 2019 0022 HP Fax page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-0 &6-7-8-9) Property Address _Village Square South Condos Owner owner's Name information is 05terville MA 02655 11-4-19 page for every CitylTown State Zip Code Date of inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) I Yes No ` Static liquid level in the distribution box above outlet invert due to an overloaded El ® or clogged SAS or cesspool ❑ ® Liquid depth in eel is less than 6" below invert or available volume is less than '/z day flow f'iT ❑ ® 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 it 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 16,303,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—IW PA)or a mapped.Zone II of a public water supply well t5insp.00c•rev,712612018 Title 5 Otfidal Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 18 Nov 06 2019 00:22 HP Fax page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form I. b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f v 39 Tower Hill Road(BLDG 5-13-D&6-7-8-9) Property Address Village Square South Condos Owner Owners Name information is required for every Osteryille MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Departmeni. 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)] l5insp.coc-rev.7/26/2018 Title 5 Official hapection Form:Subsurface Sewage Dlspoaal System•Page 6 of 18 Nov 06 2019 00:22 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-D S 6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): NA DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: 2000 Gal. Tank D Box and two pit's. Number of current residents:. NA Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): NA Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7l2612018 Title 5 Official Inspection Form-Subsurface Sewage Uiwsal System•Page 7 of 18 Nov 06 2019 00:23 HP Fax page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E 39 Tower Hill Road(BLDG 5-13-0&6-7-8-9) Property Address _Village Square South Condos Owner Owner's Name Information is required for every Osterville MA 02655 11-4-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc,): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No ^ If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes,.volume pumped: gallons How was quantity pumped determined? Reason for pumping: N Mnsp.eoc•rev.71261201a Title 5 Official Inspecticn Form:Subsurface Sewage Disposal System•Page 8 of 18 Nov 06 2019 00:23 HP Fax page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-13-D 8,6-7-8-9) Property Address Village Square South Condos Owner Owner's Name Informrequired re Osteryille MA 02655 11-4-19 required for every page. City/Town State Zip Code Date of Inspectlon 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): Depth below grade: 30" 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 inlet line 6"cast iron, outlet 4"PVC SCH 40. t5lnsp.doc•rev.7M)2016 Title 5 Official Inspection Forn Subsurface Sewage Disposal System•Page 9 of 18 Nov 06 2019 00:23 HP Fax page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-D&6-7-8-9) Property Address Village Square South Condos - Owner Owners Name information is Osterville MA 02655 11-4-19 required for every page, city/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 20-0 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal. Precast 1" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 8rr Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 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.): Tank at working level w/both covers steel at grade in grass area. Inlet and outlet tee's. No sign of leakage or over loading - t5insp.doc-rev,T/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 10 of 18 Nov 06 2019 00:23 HP Fax page 32 ,<e,\ Commonwealth of Massachusetts Title 5 Official Inspection Form I. r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vo 39 Tower Hill Road(BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Cisterville MA 02655 11-4-19 page. City/Town Slate Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: [I concrete El 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 15insp.doc-rev.712612018 Title 5 omdai inspection Form:subsurface Sewage Disposal System•Page 11 of 18 Nov 06 2019 00:23 HP Fax page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9w�" 39 Tower Hill Road(BLDG 5-B-D&6-7-8-9) Property Address Village Square South Condos Owner Owner's Name requir required is Osterville MA 02655 11-4-19 required for every page. CityfTown 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 f 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 Box is 16"x16"-30"Below grade wlcover steel at grade. Box is clean and solid wltwo line's out. y No sign of over loading or solid carry over. 15in3p.doc•rev.7r28l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Nov 06 2019 00:23 HP Fax page 34 Commonwealth of Massachusetts Title 5 Official inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 39 Tower Hill Road(BLDG 5-B-D & 6-7-8-9) Property Address Village Square South Condos Owner owner's Name information is Osterville MA 02655 11-4-19 required For every 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: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑� leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: . ❑ innovativetalternative system Type/name of technology: lbirrsp.doc•rev.712&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system Page 13 of 1a Nov, 06 2019 0024 HP Fax page 35 Commonwealth of Massachusetts 02 Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °I 39 Tower Hill Road(BLDG 5-B-D&6-7-8-9) Property Address _Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. Clty/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 two precast pits, Pit# 1 at 3' below grade wlcement cover at grade1'water in pit. Pit #2 at 4'below grade wl10" water. No sign in pits 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.): i t5insp.doc•rev.712&2018 Title 5 Otkiel Inspection Form Subsurface Sewage Disposal System-Pne 14 of 18 i Nov 06 2019 00:24 HP Fax page 36 i Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-6-D&6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osteryille MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan). Materials of construction: Dimensions Depth of solids 1 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7128/2018• Title 5 Offidel Inspeclon Form:Subsurface Sewage Disposal System-Page 15 of 18 Nov 06 2019 00:24 HP Fax page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B•0&6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-4-19 page. City/rown 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 OOR . A g r o 0 0 - � - 27 f - 1 G- 3 - siK 6A , �3 rT , t5lnsp.doc-rev.TIM2418 Tille 5 Official Inspection Form Suhaurface Sewage Disposal System Page 16 or 18 Nov 06 2019 00:25 HP Fax page 38 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos W P -V Owner Owner's Name information is Osterville MA 02655 11-4-19 required for every i page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na Estimated depth to high ground water: 13'-6" 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: 8-3.10 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.8-3-10 , no G.W.at 13'-6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6insp.doc-rev.7126/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 L Nov 06 2019 00:25 HP Fax page 39 Commonwealth of Massachusetts , Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(BLOG 543-D&6-7-8-9) Property Address Village Square South Condos Owner owner's Name informatlon Is I required for every Osterville MA 02655 11-4-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. inspector Information: Complete all fields in this section. " ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D.System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included �optf .7N ,60rloM Pir, 3��* 0 G.cv t5insp.doc•rev.V2612019 Title 5 Official inspection Form:Subsurface Sewage Disposal system•Page 76 of la Nov 17 2016 15:08 Jim The Inspector Man 5085349919 page 35 "ICA Commonwealth of Massachusetts , W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) � Property Address l Village Square South Condos Owner Owner's Name information is h" required for every Osterville MA 02655 11-14-16 6D page. City/Town State Zip Code Dale of Inspection r1a 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. Imng out forms A. General Information filling out forms � �o7t'�3- -J \`\���� k�OF on the computer; `\`��� ,.• ..ASS9c�'� use only the tab 1. Inspector: off; yG key.to move your Un cursor-do not James D.Sears JAMES use the return Name of Inspector = S_A IRS y-- key. # Capewide Enterprises LLC Company Name 7,. .5 INSPEG11`���\` 153 Commercial Street ''��►�rr,,,,,,u,,,tr�``� . Company Address ' Mashpee MA ' 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of. Title 5(310 CMR 16,000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ' ❑ Needs Further Evaluation by the Local Approving Authority -Cr'AI1:r-e. 11-14-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 underthe 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. YSins.doo.rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 . n �S L Nov 17 2016 15:09 Jim The Inspector Man 5085349919 page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 39 Tower Hill Road (BLDG 6-B-D & 6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every OSterville MA ( 02655 11-14-16 page. City/Town Statel Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 2000 Gal. Tank D Box and two pits. B) System Conditionally Passes: i i • I ❑ 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): l5ins.doc•rev.6116 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17 Nov 17 2016 15:09 Jim The Inspector Man 5085349919 page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D&6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 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 o,r 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 I_ ❑ ❑ N ❑ 'ND (Explain below): C) Further Evaluation is Required by.the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc rev.6116 7111e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Nov 17 2016 15:10 Jim The Inspector Man 5085349919 page 38 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 54-D & 6-7-8-9) i Properly Address I Village Square South Condos Owner Owners Name information is required for every OStervllle MA 02655 J 11-14-16 page. City/town State Zip Code Dale 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 GNAW is less than 6" below invert or available volume is less , than A day flow pjT S l5ins.doc-rev.6/15 Tide 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Nov 17 2016 15:10 Jim The Inspector Man ,5085349919 page 39 r' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 39 Tower Hill Road (BLDG 5-B-D & 6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osteryllle MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than.4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.,_ ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore-the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve.a facility with a design flow of 10,000 god to 15,000 god. 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 T ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drjnking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) ora mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins.doc•-vt 6116 Title 5 Official inspection Form:Subsurlace Sewage Disposal System•Page 5 of 17 1 I Nov .17 2016 15:11 Jim The Inspector Man 5085349919 4 page 40 Commonwealth,of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 39 Tower Hill Road BLDG 5-13-13& -7- -6 89 Property Address Village Square South Condos Owner Owner's Name information is required for every Cisterville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 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: ® ❑ r Existing information. For example, a plan at the Board of Health. . ® Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I . D. System Information Residential Flow conditions: F Number of bedrooms (design): NA Number of bedrooms(actual): NA m DESIGN flow based.on.310.CM14,15.203 (for example: 110 gpd x#of bedrooms)` NA. t5ins_doc•rev.6H6 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 or.17 . t Nov 17 2016 15:11 Jim The Inspector Man 5085349919 page 41 Commonwealth of Massachusetts Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form : Not for Voluntary Assessments i 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) Property Address I Village Square South Condos Owner Owners Name information is required for every �5terville MA 02655 11-14-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The systm is a 2000 Gal. Tank D Box and two pits Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? i ❑ Yes No Water meter readings if available (last 2 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310£MR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft, etc.): C Grease trap present? I ❑ Yes ❑ No Industrial waste holding tank present?' ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins.doc rev.6.116 Title 5 Official inspeaion Forth:Subsurface Sewage Disposal System•Page 7 of 17 Nov 17 2016 15:12 Jim The Inspector Man 5085349919 page 42 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D & 6-7-8-9) Property Address Village Square South Condos Owner Owners Name information is Osterville MA 02655 11-14-16 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool j ❑ Overflow cesspool 1 ❑ 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. ` El Other(describe): I 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Nov '17. 2016 15:12 Jim The Inspector Man 5085349919 page 43 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) Property Address _ Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont) 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 Building Sewer(locate on site plan).- Depth below grade: - 30" 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 inlet line 6" cast iron, outlet 4" PVC SCH 40 i Septic Tank (locate on site plan):. Depth below grade: 2Tfeet Material of construction: ® concrete ❑ metal• ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal. Precast 2° Sludge depth: i5ins.doc• ev.6116 Title 5Official Inspection Form'Subsurface sewage Disposal System•Page 9 of 17 • • I , Nov 17 2016 15:13 Jim The Inspector Man 5085349919 i page 44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D & 6-7-8-9) Property Address Village Square South Condos Owner Owners Name information is required for every Osterville MA 02655 11-14-16 page. Cityfrown State Zip Code Date of Irispection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" • Scum thickness Distance from top of scum to top of outlet tee or baffler 8" i Distance from bottom of scum to bottom of outlet tee or baffle 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.): :) Tank at workinglevel w both co vers steel at grade In grass area. Inlet and outlet tees. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet • Material of construction: ❑ concrete ❑ metal ❑ fiberglass D 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 . Nov 17 2016 15:13 Jim The Inspector Man 5085349919 page 45 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) I Property Address Village Square South Condos Owner Owner's Name information is Osteryille MA 02655 11-14-16 required For every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle_condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: I ❑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). 1s copy attached? ❑ Yes ❑ No 15iru.doc-rev 9116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page f 1 of 17 Nov 17 2016 15:13 Jim The Inspector Man 5085349919 page 46 Commonwealth of Massachusetts Titles Official . Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is Osteryille MA 02655 11-14-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) ` Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-30" Below grade w/cover steel at Grade. Box is clean and solid wltwo line's out. No sign of over loading or solid carry over. i I , 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.doc•rev.6116 Title 5 CI iciel Inspection Form:Subsurface Sewage-Disposal System-Page 12 of 17 Nov 17 2016 15:13 Jim The Inspector Man 5085349919 page 47 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments' w 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos . Owner. Owners Name information is required for every OsteNille MA 02655 11-14-16 page. City/Town - State Zip Code Date oi'Inspection D. System Information (cons.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leachingtrenches ' number„length: . . ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of'hydraulie failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pits. Pit# 1 at 3' below grade w/cement cover at grade 2'water in pit. Pit#2 at 4' below grade w/20"water. No sin in pits of overloading or soli carry over u 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 t5ins.doc•rev 6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Nov 17 2016 15:13 Jim The Inspector Man 5085349919 page 48 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments _ 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos Owner Owner's Name iv information is required for every Osterville MA 02655 11-14-16 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): t Materials of construction: Dimensions t Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Pegs 14 of 17 Nov 17 2016 15:14 Jim The Inspector Man 5085349919 page 49 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5-B-D &6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 1 t-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately IA-1 0 I 0 � l I • 15insAoc-rev.6116 Title 5 Official Inspection Form:Subeurtaoe Sewage Disposal System•Page 15 of 17 Nov 17 2016 15:14 Jim The Inspector Man 5085349919 page 50 Commonwealth of Massachusetts - Title 5 Official Inspection Form ti Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y� 39 Tower Hill Road (BLDG 5-B-D & 6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 - page. Cityrr6vn State Zip Code Date of Inspection D. System Information (cont,) Site Exam:- ❑ Check Slope j ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth to(h'igh ground water: .13-6 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: B-3-10 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. 8-3-1- on site, no G.W. at 13'-6". t - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.W6 Title 5 Offidel Inspection Form:Subsurface Sewage Disposal Syslam•Page 16 of 17 i Nov. 17 2016 15:14 Jim The Inspector Man 5085349919 page 51 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (BLDG 5.B-D&6-7-8-9) Property Address Village Square South Condos Owner Owner's Name information is required for every Osterville MA 02655 11-14-16 page. cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E.checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ' I t5ins.doc•rev.6116 - Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 Y every page. Cit /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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 anon City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the ` information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority N_ O Q { 7/20/2010 Inspector's Slgn ure Date O The system inspector shall submit a copy of this inspection report to the Approving At. rityoard of Health or DEP)within 30 days of completing this inspection. If the system is a shared syson or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall std)mime g report to the appropriate regional office of the DEP. The original should be sent to the:Rste&,owner and copies sent to the buyer, if applicable, and the approving authority. a ****This report only describes conditions at the time of inspection and under the caaditio"s 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposa ystem•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will,pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osteryllle Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 12 Number of bedrooms (actual): 12 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1320 I t5ins•09/06 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 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7/20/2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No NIndustrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is Osterville Ma. 02655 7/20/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the-inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all.components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints,venting, evidence of leakage, etc.): Joints appear tight.no evidence of leakage.system vented through the building vents. Septic Tank(locate on site plan): 20" 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 M Dimensions: 2500 gallon Sludge depth: 3" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 44" Scum thickness V. 711 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: f t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pit#1 was full to invert.Pit#2 Water level was 39" below invert at time of inspection.Stain line observed 33" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every 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 A. �Sna! 3 Sy y3 y 3 ) 1 Y t�P LP ) �f r our S t5ins•09/08 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 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 28' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L - - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 39 Tower Hill Rd. ( Units 5b,5d,6,7,8,9) Property Address Village Square south Condos Owner Owner's Name information is required for Osterville Ma. 02655 7/20/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i L has- C27s,' COMMONWEALTH OF MASSACHUSETTS T01,A N C?r' Ar„1 SABLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEdfibafU C$ M 9: 54 O YiSION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Units 5B, 5D, 6, 7, 8&9(Septic System #3) J oo;� Property Address: 39 Tower Hill Road Osterville:MA 02655 Owner's Name: Village Square South Condominium Association Owner's Address: P.O. Box 598 Osterville, MA 02655 Date of Inspection: June 11, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT 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 Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 13, 2005 The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completin 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I A Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 5B, 5D. 6,7,8,&9)-System#3 Osterville, MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 5B, 5D. 6,7,8,&9)-System#3 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic.tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 39 Tower Hill Road(Units 5B, 5D, 6,7,8.&9)-System#3 Osterville, MA Owner: Village Sguare South Condominium Association Date of Inspection: June 11, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Tower Hill Road(Units 5B, 5D, 6 7 8&9)-Svstem#3 Osterville, MA Owner: Village Sauare South Condominium Association Date of Inspection: June 11, 2005 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: Yes No ✓ _ 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(3)(b)]. 1 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: 39 Tower Hill Road(Units 5B. 5D, 6,7,8,&9)-System#3 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 FLOW CONDITIONS RESIDENTIAL 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): n/a Number of current residents: n/a Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Some units Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAVINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use:. OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped yearly for maintenance-Pumped approx. 6 weeks ago for maintenance Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approximately 1972-per design plans Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 5B 5D 6 7.8.&9)-System#3 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting;evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction:' ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2500 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 43" Scum thickness: I" 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; 16" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any s_ igns o leakage Steel covers were to grade. The tank was pumped for maintenance approximately 6 weeks ago GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 ,a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road(Units 5B, 5D 6 7 8&9)-System#3 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 TIGHT or HOLDING TANK: None (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/day Alann present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.): The D-box was level. There were no signs ofsolids PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 5B. 5D. 6,7.8.&9)-System#3 Osterville, MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2 -6'x 6'with 3.5'stone(per design plans) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): One pit(94) had approximately Y of liquid on the bottom. The other pit 03)was dry, There did not appear to be any signs of failure. Steel covers were to grade. The bottom to grade was 10.5'. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Tower Hill Road(Units 5B, 5D, 6,7,8,&9)-Svstem#3 Osterville. MA Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. A B an as 3 Sy y3 y a 3 &1�i- f3 apor S 10 , Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 39 Tower Hill Road(Units 5B. 5D. 6.7.8.&9)-System#3 Osterville. AM Owner: Village Square South Condominium Association Date of Inspection: June 11, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 43 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 43'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 Commonwealth of Massachusetts �" 0:7,;2 -004, iq Title 5 Official Inspection Form CAI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rl, t 39 Tower Hill Road (Unit10-12-14 A-D15A-D) " Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owners Name information is required for every Osterville - MA 02655 9-12-19 0 page. City/Town State Zip Code Date of Inspection-1- 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. ptttlN Important:When filling out forms A. Inspector Information on the computer, ego: JAMES yU' use only the tab James D.Sears =�; m key to move your Name of Inspector v :- cursor-do not use the return Capewide Enterprises �,•. o �a :Q key. Company Name 153 Commercial Street 'nZ/, F 5 1 N SP`EG��o��� Company Address Mashpee MA 02649 City/Town State Zip Code ieuun 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-14-19 Spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �' la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: , 6000 Gal. Tank D Box and leaching is for both tanks. D Box and leaching is for all BLDG'S. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20�years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ilt-� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information isequired or every Osteryllle MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ 'N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y []' N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road Unit10-12-14 A-D15A-D Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owners Name information is Osterville required for every - MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water El 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 i&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- r ❑ ® 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owners Name required for is every Osterville required for eve MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 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 i ❑ ❑ 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 �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is every OSterville required for eve MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CM 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)] N t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts' 5 Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 ' 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): - 32 Number of bedrooms (actual): 32 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3520 Description: 6000 Gal. Tank D Box and six pit's. Note: All units are H2O Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? El Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal.use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts F. Title 5 Official Inspection Form 10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . �V 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name required for is every Osterville required for eve MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below) 3. Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) - Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool' ❑ Overflow cesspool ❑ Privy ® Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Around 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 55"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 PVC SCH 40. M t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts IT, Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road Unit10-12-14 A-D15A-D Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owners Name required for is every Osterville required for eve MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): . Depth below grade: 43"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ pol eth lene y y El 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: 6000 Gal. Precast H-20 Sludge depth: 411 Distance from top of sludge to bottom of outlet tee or baffle 5'-A 0" Scum thickness 2.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 2'- 3" 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.): Tank at working level w/both covers steel at grade in grass area. In and outlet tee's. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is required for every Ostervllle MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name isrequired for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 7' below grade w/steel cover at grade in black top barking lot. Six lines out. No sign of over loading or solid carry over. f t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts 19 Title 5 Official Inspection Form �= a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road Unit10-12-14 A-D15A-D Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owners Name information isequired or every Osteryille MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: El 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 ip Title 5 Official Inspection Form- eSubsurface Sewage Disposal System Form -Not for Voluntary Assessments gas r� 39 Tower Hill Road Unit10-12-14 A-D15A-D Property Address Village Square North Condos Un.its20 A-0:21 A- .: Ais t 9-12-19 929B, -If T , a �s of Inspection .D. System Information (oom,-) 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 Six Pits 1-2-3 have 3'water Pit 4 water level at 1' below inlet Pit's 5 6 2'water 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .V 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owners Name informationis required uired for every Osteryille MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Sep 0519,04:05p Capewide Enterprises 508-477-4977 p.18 Sep 22 2016 20.54 Jim The Inspector Man 5085349919 page 35 + r lo,�j,1a r a.' c I To tone aa,ai < I f Sep 0519,04;05p Capewide Enterprises 508-477-4977 p,19 f ' © S - , 70 rb ^r ' '.� , r 9E a6ed w6hE5805 uew Jopadsul aq L4r V5.02 9102 ZZ daS c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is required for every Osteryille MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 40+' Estimated depth tort (ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Per past reports 40'+to G.W.. I Before o e 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit10-12-14 A-D15A-D) Property Address Village Square North Condos (Units20 A-D 21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 Sep 22 2016 20:51 Jim The Inspector Man 5085349919 page 20 7 t r` L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road(Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name information is required,for every Ostervllle MA 02655 . 9-15-16 page. CityrTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may h6t.be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information c filling forms 5-4 on the computer. !/ Sx OF r44,4 use only the tab 1. Inspector. ����'• o�' key to move your $O� •'•yG cursor-do not James D. Sears JAMES m" use the return Name of Inspector key. Capewide Enterprises, LLC �,•,o o ay Company Name r-1'A, FIT I T-1 '•'AQ A::F 153 Commercial Street ''�'i,, HtP Company Address — • Mashpee MA 02649 Cityrrown State Zip.Code 508-477-8877 S1523 ~ Telephone Number License Number t 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 t i 9-19-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate t 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. s ""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.cloc•rev.W16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 or 17 � y ,r ' Sep 22 2016 20:51 Jim The Inspector Man 5085349919 page 21 t Commonwealth of Massachusetts Title 5 Official -inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name 1 information Is Osterville MA 026.55 9-15-16 required for every E page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes; ® 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 I indicated below. F Comments: D Box and leaching is for both tanks. D Box and leaching is for all BLDG'S. i 3 13) System_Conditionally Passes: E ❑ 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 imrriinent. 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):- f i t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t I' Sep 22 2016 20:51 Jim The Inspector Man 5085349919 page 22 t I i Commonwealth of Massachusetts =: Title .5 Official Inspection Form Subsurface Sewage Disposal System Form_Not for Voluntary Assessments 39 Tower Hill Road (Unitsl0-12-14 A-D 15-A-D) Property Address Village Square North Condos_ (Units 20 A-D 21 A-D) Owner Owner's Name information is { required for every Osterville MA 02655 9-15-16 page. CitylTown 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): i t ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y_ ❑ N ❑ ND (Explain below): i 1 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 50jfeet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh I5ins.doc•rave.&16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i. 1 Sep 22 2016 20:52 Jim The Inspector Man 5085349919 page 23 . I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 °y 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address - Village Square North Condos(Units 20,A-D 21 A-p) Owner Owner's Name t information is required for every Osterville MA 02655 9-15,16 page. City/Town State Zip Code Date of Inspection t 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water i supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet,but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. f 3. Other: I f l 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 El ® Discharge or ponding of effluent to-the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in is less than 6" below invert or available volume is less- than '/Z day flow p;r.5 l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 I t Sep 22 2016 20:52 Jim The Inspector Man 5085349919 page 24 i t t Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (UnitS10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner. Owner's Name 6 information is / required for every Osterville MA 02655 9-15-1,6 i page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy.is below high ground water elevation. a ® 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. s ❑ ® 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 tri i p triggered.A copy of the analysis. and chain of custody must be attached to this form.] El The system is a cesspool serving a facility with a design flow of 2000gpd- 1. ® 10,000gpd. 11 ® 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 m design flow of 10,000 gpd to 15,000 gpd. i 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 ❑ El the system is located in a nitrogen sensitive area(Interim Wellhead Protection 1 Area—IWPA)or 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 . t 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t Sep 22 2016 20:52 Jim The Inspector Tian ouozm,+"i y r�y� f i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forml-Not for Voluntary Assessments t 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21.A-D) Owner Owner's Name s information is required for every . Osterville MA 02656 . 9-15-16 i page.. Cityrrown State. Zip Code Date of Jnspect+on 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 t ❑ ® Were any of the system components pumped out in the previous two w.ek&? r i ® ❑ 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 r ❑ ® this inspection? - Were as built plans of the system obtained and examined? (If they were; .lot ® available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? I ® ❑ Were all system components, excluding the SAS, located,on site? E i s ® ❑ Were the septic tank!manholes uncovered, opened, and the interior d. IN. tank inspected for the condition of the baffles or tees, material of construdtion,` ' dimensions, depth of,liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with El m information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site hta g 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 id;sue approximation of distance is unacceptable) (310 CMR 15.302(5)] t - - t D. System Information Residential Flow Conditions: x 32 1 Number of bedrooms(design): 32 - Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3520 : i i Title 5 official Inspection Form.Subsurface Sewage Disposal.System•page 6 of V { t5ins.doc•r-.6/16 - - - ' E t Sep 22 2016 20:52 Jim The Inspector Man 5085349919 page 26 L Commonwealth of,Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments y 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address t Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name information is d required for every Osterville MA 02655 9-15-16 page. Cityfrown State Zip Code Date of Inspection D. System Information - t Description: The system is a 6000 Gal. Tank D Box and six pits Note: all units are H2O _ I 1 t L Number of current residents: NA 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.) . t Laundry system inspected? ❑ Yes ® No ; Seasonal use? El Yes ® No Water meter readings, if available(last 2 years usage(gpd)): NA Detail: I i i Sump pump? ❑ Yes ® No f Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gPd) Basis of design flow(seats/persons/sq.fl., etc.): 3 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`. i s 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 j Sep 22 2016 20:52 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 39 Tower Hill Road (Unitsl0-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name information is required for.every Osterville MA 02655 9-15-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I Last date of occupancy/use: Date Other(describe below): t r i . i General Information t t Pumping Records: t Source of information: Yearly Pumping. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping Type of System: ® Septic tank, distribution box; soil absorption system I ❑ Single cesspool ❑ Overflow cesspool ❑ Privy I [ ® Shared system (yes or no) (if yes, attach previous inspection records, if any ❑ Innovative/Alternative technology.Attach 8 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. 1 ❑ Other(describe): t5irwdoc•rev.6116 Title 5 Offoal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 • I i f Sep 22 2016 20:53 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner. Owner's Name information is required for every Osterville MA 02655 9-15-16 page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) E _ I Approximate age of all components, date installed (if known)and source of information. Around 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 55" ` feet ' t 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 PVC SCH 40. S r Septic Tank (locate on site plan): - 43" Depth below grade: rt er z Material of construction: s ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) E r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ¢ Dimensions: 6000 Gal.•Precast I Sludge depth: 2., t t5ins.doc-rev-6116 Title 5 Official Inspection rorrn'Subsurface Sewage 01ep08al System•Page 9 of 17 YSep 22 2016 20:53 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Witte 5 Official Inspection p®rr'n ,. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. i 39 Tower Hill Road (Unitsl0-12-14 A-ID 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name information is Osterville MA 02655 9-15-16 required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) - S 6' 2" Distance from top of sludge to bottom of outlet tee or.baffle i 2" 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 2'- 3" 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.): Tank at working level wlboth covers steel at grade in grass area. In and outlet tees. No sign of leakage or over loading. - i r Grease Trap(locate on site plan): Depth below grade: feet Material of construction: i • _ i ❑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 . 15ins.doc rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r w Sep .22 2016 20:53 Jim The Inspector Man 5085349919 - page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-15-16 page., CitylTown 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; t 3 Material of construction: i concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Capacity: gallons i Design Flow: gallons per day Alarm present: E Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping; Date Comments(condition of alarm and float switches, etc.): y I 4 *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i t5ins.doc•rev.6/16 - Title 5 Official Inspection Fond:Subsurfa=e Sewage Oisposel System•Page 11 of U ` I Sep 22 2016 20:53 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts ra Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) i Owner owner's Name information is Oster MA 02655 9-15-1-6- required for every page. City/Town State Zip Code. Date of Inspection D. System Information.(cont.) Distribution Box (if present must be opened) (locate on site plan): . Depth.of liquid level above outlet invert 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 7' below grade w/steel cover at grade in black top parking lot, Six line's out. No sign of t over loading or solid carry over. - i Pump Chamber(locate on site plan): i 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): • s If SAS not located,.explain why: I i t 15ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 , i r I Sep 22 2016 20:53 Jim The Inspector Man 5085.349919 page 32 I Commonwealth of Massachusetts � a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D 21 A-D) Owner Owner's Name information is Osterville MA 02655 9-15-16 1 required for every , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: 6 ® leaching pits. number. r ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,level of,ponding, damp soil, condition of vegetation, etc.): i Leaching is six precast pits w/steel cover at grade. Pits# 1-2 has 4'water. Pit's#3-5-6-dry. Pit ` #4 Full. Pits are 10' deep. 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 E Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No -ESins.doc rev.6118 - Title 5 Official Inspection Form:Subsurface Sewage Disposal Sycem•Page 13 of 17 I f - Sep 22 2016 20:53 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts W Title ,5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) r Property Address Village Square North Condos(Units 20 A-D 21 A-D) Owner Owner's Name information is required for every Cisterville MA 02555 9-15-16 page. CityrTown State Zip Code Date of Inspection s D. System Information (cost) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 7 y Privy (locate on site plan): Materials of construction: F Dimensions Depth of solids , Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, } etc.): , I i 1 t5ins.doc•rev.6116 Title 5 Official Inspection Fonre Subsurface Sewage Disposal System•Page 14 of 17 Sep 22 2016 20:53 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments e a' 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) M J Property Address } Village Square North Condos(Units 20 A-D 21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-15-16 r 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 . 1 r f i i i 15ins.doc-rev.6116 - Title 5 Official Inspection Form:Subsurlace Sewage Disposal System•Page 15 of 17_ t 3 Sep 22 2016 20:54 Jim The Inspector Mari 5085349919 page 35 �W Bft To Un rfj I too n, la , ain 11-5 Onirf _ F 1-7 o - - 00 4r.S a V N _ n 4i .y I— O • O N n Sep 22 2016 20:54 Jim The Inspector Man 5085349919 page 37 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Un its 10-12-14 A-D 15 A-D) Property Address Village Square North Condos (Units 20 A-D`21 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-15-16.. i page. CityfTown State Zip•Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check SlopE. ❑ Surface water ❑ Check cellar ❑ Shallow wells t N° Estimated depth to high ground water: 40+' 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 - i ❑ 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 1 You must describe how you established the high ground water elevation: Per past reports 40'+ to G.W. i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsins.doc,•rev.am - Title 5Official Inspection Form:Subsurlace Sewage Disposal System•Page 16 of 17 f Sep 22 2016 20:54 Jim The Inspector Man 5085349919 page 38 Commonwealth of Massachusetts . Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Units10-12-14 A-D 15 A-D) Property Address Village Square North.Condos (Units 20 A-D 21 A-D) Owner Owners Name information is paterville MA 02655 9-15-16 required for every r page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information-Estimated depth to-high groundwater. ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r i t 9 - i • s ' L f i l5ins.doc•rev.Gliw Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 D '? -C\ Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•" 39 Tower Hill Rd. ( Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. Genera! Information filling out forms ���0` �N OF MA on the computer, use only he tab 1. Inspector ��```�� SS9cyG key to move your G �; .N cursor-do not yO� � 3�; DAMES .�_ James D.Sears =o: EARS use the return Name of Inspector = S *i key. CapewideEnterprises,LLC y� RTIF ap Company Name •I N Sp \\`��Z 153 Commercial St. '''"��►muuliu►"`°� Company Address Mashpee MA 02649 City/Town. State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t Pt-J-19w� 9-5-13 ' spector•s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. `This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 11`1#j 9111113 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonweal# of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown 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: D Box and leaching is for both tanks. D Box and leaching is for all BLDG'S. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 official Inspection fomL Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 39 Tower Hill Rd. ( Units 10- 12,14b-d,. 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 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 pumpstalarms 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 i . Th❑ y eq p p g y stru ed p pe(s) e system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,N 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 sessaM is less than 6°below invert or available volume is less than%day flow Ai .s t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 } Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pie 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityr town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes'or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 32 Number of bedrooms(actual): 32 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3520 t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville AAA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 6000 Gal.Tank D Box and six pits. Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA g ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official inspection Fort:Subswiace Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. (Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. cityrrown State Zip Code Date of Inspedion D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Around 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " 55 Depth below grade: 56 feet Material of construction: ❑cast iron Z 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 PVC SCH 40 Septic Tank(locate on site plan): ' Depth below grade: 43"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: 6000 Gal. Precast Sludge depth: 1" t5ins•3113 Title 5 official 'on Form:Subsurface Disposal System•Page 9 of 17 tnspecb Sewage pose yst a9 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owners Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 6-3" Scum thickness let Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 2'-4" How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level w/both cover's steel,at grade in grass area. In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal { ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Tdle 5 Ofrrcial Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 39 Tower Hill Rd ( Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owners Name information is reequiredred for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 39 Tower Hill Rd. ( Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid Level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 7' below grade w/steel cover at grade,in black top parking lot. Six 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. I Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subs face Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. (Units 10- 12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspedion D. System Information (cunt.) Type: ® leaching pits number: 6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is six precast pits w/steel covers at grade. Pits#1&2 Have 5'water. Pits#3,5,6 are dry. Pit #4 is Full. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . d 39 Tower Hill Rd. ( Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owners Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•3(13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 39 Tower Hill Rd. ('Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3M 3 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Aug, 29. 2013 2:04PM No. 1676 P. 26 Fall,cr fly 10 r7 �.� T � ao ,�, , �:,� .:Sn F�? iw t ' � ♦ � •� ' "�v ,!!! � �.t 3 � ,� �a �v, j r � "` � ;. � ,ales® .. ��, � � {IA .. ��� � ��; ��,,` .. ��-� �� u _ ,.. ,s:nta .. ... .. .. , u .. .. ., .i, ,. •;4 .. � ... i .f �,. '... '... �... a �� .. .. ". �-J' 1 8/� ;4 t .. .,. .� .,,. � 's: � 9 '� 'y 4! .. .,. ... ,. ,.. � _ ,..r.� .,.. :a �..J . � �. � :.� .. .. y.,�. . .�:h �..r � n .. � f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. (!Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13. page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 0 Al Estimated depth tofh-igh ground water: 40+' 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: Data ❑ 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: Per Past Reports 40+'to G.W... Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3H 3 Me 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 10-12,14b-d, 15a-d,20 a-d,21a-d) Property Address Village Square North Condos Owner Owner's Name information is Osterville MA 02655 9-5-13 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary. A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i ova - 00A Commonwealth of Massachusetts Title 5 Official Inspection Form r , <F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IA i NJ 39 Tower Hill Road Unit16 A-D 17 A-D) � Property Address Village Square North Condos (18 A-D 19A-D) M Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 :; page. City/Town State ' Zip Code Date of Inspection y y_3 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. V`I\A OF Important:When A. Inspector Information ���s.J a3 �' filling out forms q1 ZF_� *1 y� on the computer, JA M E S u' use only the tab James D.Sears =`�. .104= key to move your Name of Inspector c„a cursor-do not CEnterprises *' a ewide s �'•.o o; use the return �, F ,• 8`_ key. Company Name �F 5 EG�����• 153 Commercial Street Company Address Mashpee MA . 02649 City/Town State Zip Code �ara 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails P 9-12-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 9form should be sent to the system owner and copies sent to Y 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of.the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 6000 Gal. Tank. D Box and leaching is for both tank's. D Box and leaching is for all BLDG'S 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 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or'break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y '❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, I 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,u 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No I ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool I ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form t a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;V 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in }is less than 6" below invert or available volume is less than '/z day flow P<7s ❑ ® 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 t51nsp.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 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos_(18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 32 Number of bedrooms (actual): 32 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3520 Description: 6000 Gal.Tank D Box and six pit's. Note: All units are H-20. Number of current residents: NA 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? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form +' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) ' Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ 'No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owners Name information is required for every Ostervllle MA 02655 9-12=19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system (yes or no) (if yes,°attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest -inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Around 1960 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 45"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 PVC SCH 40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form jo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 33"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: 6000 Gal. Precast H-20 Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 6' 2 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 2' 3" 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.): Tank at working ilevel w/both cover's steel,at grade. In and outlet tees. No sign of leakage or over loading. t in 5 sp.doc-rev.7126/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness, Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) V Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osteryille MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 4 *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 Box is 7' below grade w/steel cover at grade in black top parking lot. Six line's out. No sign of over loading or solid carry over. i 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 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 6 I ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) , 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is Six Pit,s 1-2-3 have 3'water. Pit 4 water level at 1' below inlet .Pit's 5-6 2'water. 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.): L t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address I Village Square North Condos (18 A-D 19A-D) Owner Owners Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: , Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately • ti 15insp.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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts . p Title 5 Official Inspection Form IG li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Unit16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to 40+'ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Per past report 40"-to G.W.. I 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 Sep 22 2016 20:50 .fim The Inspector Man 5085349919 page 17 Sep. B. 2416 l:25PM No, 1291• P. 19/23 I a 1 • v • 1 I = Cc • I 11f I • I 1 . I � � 1 l i I i i 8£'d LL6b-LLV-809 sesiadjelu3 ep!medeC) d60:t,0'66 90 deS L ri M � O 1 �• .13bto w A • a m J., w W CL rn 1 o - v 0 of 0 a m �p 22 2016 20:49 Jim The Inspector Man 5085349919 page 1 �® Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments r 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos(18 A-D 19 A-D) Owner Owners Name / information is required for every OSteryllle MA 02655 9-15-16 page. Citylrown 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. General Information fillin.gouiforms �/#. //SBJ? \1��t►HnIUUHrpi� on the computer, ���� ZH OF use only the tab 1. Inspector: �����`` key to move your - JAIVIES G ' cursor-do not James D.Sears = m use the return Name of InspectorMin UN 0 Rey.. p Ca ewide Enterprises, LLC ' Company Name •.,• i i r 153 Commercial Street y��i''nh I N SP1E`\���o`` Company Address Mashpee MA 02649 Cityrrown State Zip Code 608-477-8877 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 0 Needs Further Evaluation by the'Local Approving Authority . 9-19-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the,Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. y ""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. t5im.cloc-rev.6116 Title 5 Official Inspection Fort:Subsurface Sewage Disposal system•Page 1 of 17 �o Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form P Subsurface Sewage Disposal System form -'Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owners Name information is ` required for every Osterville MA 02655 9-15-16 . page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: D Box and leaching is for both tank's. D Box and leaching is for all BLDG'S B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6r16 Title 5 01ficial Impection Form:Subsurface Sewage Disposal System•Page 2 of 17 Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owners Name information is required for every OStervllle MA , 02655 9-15-16` page. City/Town State Zip Code Dale 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.(cost.): ❑ 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 t❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑`Y E ❑ 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: El 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 t5lns.doc rev._5116 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-15-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 th.e'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 ofIa.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 is less than 6" below invert or available volume is less than '/z day flow 12l7S t5ins.doc rev.GJ16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts i Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owner's Name information is required for every Osterville MA 02655 9-15-16 Page, Cityr town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any,portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet,of a private water supply well, ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis r, and chain of custody,must be attached to this form.) ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that.one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the . questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim,Wellhead Protection Area,—IWPA)or a mapped Zone II of a public water supply.well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304• The system owner should contact the appropriate regional office of the Department.' 15ins dod•rev.6116 Tilla 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 5 of 17 Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments ay 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owner's Name information is Osterville MA 02655 9-15-16 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ® 0 Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® . ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The 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 E approximation of distance is unacceptable) [310 CMR 15.302(5)] r D. System Information Residential Flow Conditions: Number of bedrooms(design): 32. Number of bedrooms (actual): 32 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 3520 tsins.doc•rev.6115 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page .7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments- 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19.A-D) Owner Owner's Name information isequirred for every very Osterville MA 02655 9-15-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 6000 Gal. Tank D Box and six pits. Note:All units are H-20. d Number of current residents: NA 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)): NA Detail: - Sump pump? ❑ Yes ® No Last date of occupancy: Present Date a 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: - t5ins,doc-rev-6116 - - - Title 5 Official Inspection Form:Subsurface Sewage.Disposel System-Page 7 of 17 Sep 22 2016 20:49 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.,•'t 39 Tower Hill Road (Units 16 A-D 17 A-D) ` Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owner's Name information is Osterville MA 02655 9-15-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: date Other(describe below): F t General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as.part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined . Reason for pumping: Type of System: 1 ® Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy - ® Shared system (yes or no) (if yes, attach previous inspection records, if any) T ❑ 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.doc.rev.6(16 Title 5 Official Inspection Form:Subsurface Se,'sge Disposal System.Page 8 of 17 . Sep. 22 2016 20:49 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f 39 Tower Hill Road (Units 16 A-D 17 A-D) . Property Address Village Square North Condos (18.A-D 19 A-D) Owner Owner's Name information is required for every Ostefville MA 02655 9-15-16 requ page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: f Around 1980 Were sewage odors detected when arriving at.the site? ❑ .Yes ® No Building Sewer(locate on site plan): 45° Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): t Distance from private water supply well or suction line: feet Comments (on condition of joints; venting, evidence of leakage, etc.): Pipeing is PVC SCH-40. i Septic Tank (locate on site plan): Depth below grade: 33. 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: 6000 Gal. Precast Sludge depth:. 7t 151ns.doc•rev.6116 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts W Title .5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) t Owner Owner's Name information is Osteryille MA 02655 9-15-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 61 211 Scum thickness 011 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 2' 5° How were dimensions determined? Asbuit-Tape Sludge Judge 9 Comments (on pumping recommendations, inlet and outletRtee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at woring'level w/both cover's steel at grade. In and outlet tee's. No sign of leakage or over loading. c 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 t6ins.doc•rev:6116 Title 6 Official Inspection Form:Subsurfa a Sewage Disposal System-Page 10 of 17 i Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 11 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos(18 A-D 19 A-D) Owner Owners Name information is Osterville MA 02655 9-15-16 required for every r page. CitylTown 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.): t Tight or Holding Tank(tank must be p6mped at time of inspection) (locate.on,site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): c Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm In working order: ❑ Yes ,❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i Attach copy of current pumping contract(required). Is copy,attached? ❑ Yes ❑'No 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owners Name information is required for every Osterville MA 02655 9-15-16 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 7' beiow grade w/steel cover at grade in black top parking lot. Six line's out. No sign of over loading or solid carryover - i Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* t 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: i 15ins.doc•rev 6/16 Title 5 Official Inspecion Form:Subsurface Sewage Disposal System•Page 12 of 17 Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 13 f. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19'A-D) Owner Owner's Name information is required for every Osteryille MA 02655 9-15-16 page. Cityfrown State Zip Code . Date of Inspection 1. D. System Information (cont.) r Type: ® leaching pits number: 6 , ❑ leaching chambersv number: ❑ leaching galleries number: i i ❑ leaching trenches number, length: 71 ❑ 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 six precast pits w/steel cover's at grade. Pits# 1-2 have 4' of water. Pits#3-5 -6 are dry. Pit#4 is full. Note; Pits are 10'deep. v Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): f 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.doc rev.6116 Tille 5 Official Inspaction Form:Subsurface Sawege Disposal System•Page 13 of 17 Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Properly Address Village Square North Condos (18 A-D 19 A-D) Owner Owners Name information is required for every Osterville MA 02655 9-15-16 page. Cityrrown State Zip Code Date of Inspection- D. System Information (cont.) 1 . Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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.): - c 1 d 15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage bisposal System Page 14 of 17 Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title .5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos (18 A-D 19 A-D) Owner Owner's Name information is Osterville required for every MA 02655_ 9-15-16 page. CitylTown 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 E i 15ins.doc-rev.6116 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 of 17 cn rD � O O w n - • a 3 Lyl O r 00 cn w CD aj Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 17 Sep. 8, 2016 1 : 25PM No\2291, P, 19/23 • i a r . 00 _ F r ti c i w t . 1 1 t Sep 22 2016 20:50 Jim The Inspector Man 5085349919 page 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) Property Address Village Square North Condos(18 A-D 19 A-D) Owner information is Owner's Name $ required for every Osterville MA 02655 9-1546 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water 1 ❑ Check cellar I ❑ Shallow wells Estimated depth to 40+ ph ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: t Date s ❑ Observed site (abutting property/observation hole within 150 feet.of SAS) I ® 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 Per past reports 40'+to G.W.. I Bef ore filin this Inspection Report, please see Report Completeness Checklist on next page. I5ins.doc•rev.61% Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.16 of 17 . t } Sep 22 2016 20:51 Jim The Inspector Man 5085349919 page 19 r .y Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 Tower Hill Road (Units 16 A-D 17 A-D) t Property Address � I Village Square North Condos (18 A-D 19 A-D) . Owner Owners Name information is required for every OsteNllle MA. 02655 9-15-16' page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked , ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t G t ` S t5ins.rloc-rev.6f 16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Y Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A General Information on the computer, `��������SH OF rl44 ip""" use only the tab Hf p 0� ������'' ...... SS1c�.z key to move your 1• Inspector: , o �G cursor-do not James D.Sears ; JA M E S rt, use the return Name of Inspectors v: — key. i* :W CapewideEnterprises,LLC � Company Name �, � ••..,. , • � �� 153 Commercial St. Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-5-13 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system.owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Ofiaal trnfon o .Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. (Units 16a-d,1 7a-d,1 8a-d,1 9a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town 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: ® 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: D Box and leaching is for both tanks. D Box and leaching is for all BLDG'S. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•W 3 Title 5 Official Insp ection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealdi of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown 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): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Fom.Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water 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 s1 is less than 6"below invert or available volume is less than%day flow 7� t5ins•3f13 Title 5 Olfidal Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system falls. 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•X13 Title 5 Ofridal Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 32 Number of bedrooms(actual): 32 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3520 t5ins•3/13 Title 5 Official Inspection Form:Stsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 6000 Gal.Tank D Box and six pits. Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y g (gp ))� Detail: Sump pump? ❑ Yes No Last date of occupancy: Present Date CommerciaMndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official nsped ionForm:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,1 8a-d,1 9a-d) Property Address Village Square North Condos Owner Owner's Name information is Osterville MA 02655 9-5-13 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Around 1980 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 55"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 PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 4311 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: 6000 Gal. Precast Sludge depth: 1" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 6'-3" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 2'-4" 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.): Tank at working level w/both covers steel,at grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,1 7a-d,1 8a-d,1 9a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallon§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 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos , Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 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 7' below grade w/steel cover at grade,in blacktop parking lot. Six Iine'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: p y t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is six precast pits w/steel covers at grade. Pits#1&2 Have 5 water. Pits#3,5,6 are dry. Pit #4 is Full. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,1 7a-d,1 8a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 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.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 OMdal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 39 Tower Hill Rd. ( Units 16a-d,17a-d,1 8a-d,1 9a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osterville MA 02655 9-5-13 page. City/Town State Zip Code Date of inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Aug. 29. 2013 2:05PM No. 1876 P. 30 f P . J8�•a 77 '�O 0•�c fS �7 S 4 F .�� p" T : 1p ks 3; C '� d , r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jr 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osteryille MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N° Estimated depth toRigh ground water: 4 feeett 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: Per Past Reports 40+'to G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 a V Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'rt 39 Tower Hill Rd. ( Units 16a-d,17a-d,18a-d,19a-d) Property Address Village Square North Condos Owner Owner's Name information is required for every Osteryilie MA 02655 9-5-13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1