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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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
3-12-15
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 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.
/1-5
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t5ins-3/13 Title 5 Official Vorm: urface Sewage Dispbsal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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:
System is in good working order with no sign of failure.
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 ears old or the septic tank whether metal or not is structural)
P Y P ( ) Y
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•3/13 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
°M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
1
y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
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
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 Y2 day flow
t5ins•3f13 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 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
Were all system components, excluding® ❑ y P 9 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): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 220
/
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
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•3113 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 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator,under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Ip Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2007
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 6"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 3-12-15
required for every y
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
20"
Scum thickness
1"
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
15"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
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•3/13 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 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from chambers.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers . number: 2-500's
❑ 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.):
Leach chambers in good condition and empty at inspection with no visible stain lines.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
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 Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
m w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
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
_.
r B
t5ins•3/13 Tide 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
45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-12-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
rm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 45 Buckwood Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is H
required for every y annis MA 02601 3-12-15
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
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y�
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for i$tl0 ar *p�tCIYY CotYgtrUCtiott "Individual
tApplication for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System Components
./ —
Location Address or Lot No. 7� ,���'61 � Owner's Name,Address,and Tel.No. L.�C/16/111
S,wry' ys& w-1')�L
Assessor's Map/Parcel
� 1G2-/ ;;��lsrf�lr3
Installer's Name,Address,and Tel.No./�-41�v �JA Designer's Name,Address and Tel.No.!,p�'�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) v'l�l1 gpd Design flow provided �� gpd
Plan Date 7a,,ir O/, —?cy`7 Number of sheets Revision Date
Title f.Xe yr /�r/ol�rcG6c,
Size of Septic Tank �,6bd GF C 4s�c•e41 Type of S.A.S. — f2�d 4 C'0".Jj,_j
Description of Soiltt �`6a
Nature of Repairs or Alterations(Answer when applicable) A Vm-- Lev,-C401 /per•— �G�
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructio maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Env' nme at Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He
Signed A Date � l d�--
Application Approved by Date ({
Application Disapproved by: Date
for the following reasons
Permit No. s w?,2 6 Y Date Issued
n _ ••--•..,.� -+.Kwr�.,r.�yr,.,rtt- •r*:,.:..-t::---�•5" .-"`fit,.. =ee-'y-.�.�L:.e-:-8�-'--•.s�—r-^..�.-.�..,-----�-. w�
No. 7 �/ L/ " x. ' � �.f �C� . v 3 Fee X/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
RppYication for w5pogar *pgtem Con-Itruction Permit
Application for a Permit to Construct O Repair(Y) Upgrade O Abandon O ❑Complete System Individual Components
e Location Address or Lot No. 07 51tAonvi /9 15 Owner's Name,Address,and Tel.No. Z-e CAP-/1
Assessor's Map/Parcel
702 4+V170.
Installer's Name,Address,and Tel.No. /i Designer's Name,Address and Tel.No: rlJ�
y; GE,
Type of Building:
,Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
f d 1
Design Flow(min.required) ,►'LC9 gpd Design flow provided 3� gpd
Plan Date JC/wt //• -�'C70`7 Number of sheets / Revision Date
'Title S,,if
Si etic Tank of Se /
�•s 1 P , tJUd G'� ( L'.r�1<ret Type of S.A.S. � - fro
:D ription of Soil
Nature of Repairs.or Alterations(Answer when applicable) 14�7►/9c1.- 1 t f ,I�„ �Z91
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructi�onsatid maintenance of the afore describe$on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmeri al Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date CO (9"f 0-4-
4
Application Approved by (?:. Date / �,, AG 7
Application Disapproved by: Date
for the following reasons
Permit No. C Ij? 2- Date Issued
----_--------------------------- f—'--------------
THE COMMONWEALTH OF MASSACHUSETTS -
T BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS"IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( )
Abandoned( )byi
at 31r 13111-,41 G711. Vrisf�>f� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ?Cd!-7 'fib `7 dated b ,�0 7
/ r t �
Installer / r�rJ��'All, �� / Designer IO✓ 6 p•. r1 ,,,li.+.r^iH r
#bedrooms .� i+ 'Z 0�. Approved design flow azto gpd
The issuance of this permit,shall not e co strued spa/guarantee that the system will Function as designed �Q C
Date Inspecto �; /
r. /, _ /
^^��//' �,J ——— — —---------v— -----�----
No. 2 oo l- a+�i. % Fee AJW � f
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION.—BARNSTABLE, MASSACHUSETTS
lig;poe;al 6pgtem Construction Permit
Permission is hereby granted to Construct ( ) Repair (y) Upgrade ( ) Abandon ( )
System located at yr /3d�. �odel /�/1 , G,,,,ra
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this(plermit.
Date to6 () Approved by 1 0� ,,N
I °
Town of Barnstable
"E'er Regulatory Services
q" Thomas F. Geiler, Director
WAM Public Health. Division
art' Thomas McKean, Director
200 Main Street,Hyannis, MA.02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Desianer-Certification Form
Date: O`� Sem,age Permitgo;10B-7 _)6/ Assessor's Map\Parcel C�9a
Designer: 0 v� VI e I y1eQ vi Installer:
Address: 3 Hal �/ � " Address: / �0 X �D
�- �� �l(�
On o7�'G'� / Ii�1�' �`� ��'� issued a permit to install a
(date) (installer)f1
septic system at -� �LlC�(A)D a r�C �JJ►'j ✓� based on a design drawn by
(address)
c5L& dated 611
(desll er)
I certin that the septic system referenced above was installed substantially according to
the design. which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed -'Arith major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance A ith State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF P4A q c
ARNE H y�N
U OJALA N
(Ins is Signature) CIVIL
No. 307s2
NAL Err
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Hea)NSeptic/Designer Cenification Form 3-26-04.doc
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(Endorsement Required) Z cy
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Certified Mail Provides: as�anayJyppZeunf'008Ewio a A mailing receipt d Sd
t
o A unique identifier for your mailpiece
'o A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile.
o Certified Mail is not available for any class of international mail.
e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
e For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is
required.
a For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail..
IMPORTANT:Save this receipt and present it when making an inquiry.
Internet access,to delivery information is not available on mail
addressed to APOs and FPOs.
Town of Barnstable
�F THE Tp�
o Regulatory Services
Thomas F. Geiler,Director
9�A MASS. •��p Public Health Division
1f0.�a,
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
May 22, 2007
Ms Barbara LeClaire
45 Buckwood Drive
Hyannis, MA 02601
The septic system located at 45 Buckwood Drive, Hyannis MA was last inspected on
March 26th, 2007,by Patrick M. O'Connell, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Fails"under the guidelines
o -17995 TITLE 5-(-310--CMR-I5-.-00)-due to-the mellowing:
System is in hydraulic failure
You have 60 days from the date of the system failure to bring the system into
compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable
Health Department.
BARNSTABLE HEALTH D PARTMENT
v /
Thom A. McKean,R.S., C.H.O.
Agent of the Board of Health
COMMONWEALTH OF MASSACHUSETTS
W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
,.
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
W
/� v0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 45 Buckwood Drive
Hyannis MA 02601
Owner's Name: Barbara LeClaire
Owner's Address: Same
Date of Inspection: March 26,2007 Job#07-49
Name of Inspector: PATRICK M.O'CONNELL l -
Company Name: SEPTIC INSPECTION SERVICES CO.
—c Z -Mailing Address: 189 CAMMETT ROAD t
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION,STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infor ation roperted
below is true,accurate and complete as of the time of the inspection.The inspection was performed sed on n9 rn
training and experience in the proper function and maintenance of on site sewage disposal systems. I. m 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
_X Fails
Inspector's Signature: t�`C
g V" Date: 3/26/07
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.
Notes and Comments: Leaching pit previously full to top indicating hydraulic failure. Observed solids on top
of outlet baffle in septic tank. Outlet baffle in tank is cracked and must be replaced with a PVC tee when new
leaching system is installed.
****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.
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
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:
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 I 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:
Page 4 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
—X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
—X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone I of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X_ 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.)
_Yes_(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 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.
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.
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period ?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ Was the facility or dwelling inspected for signs of sewage back up
_X_ _ Was the site inspected for signs of break out
_X_ _ Were all system components,excluding the SAS, located on site
_X_ _ 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
_X_ _ 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
_X_ Existing information. For example,a plan at the Board of Health.
X_ _ 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)]
Page 6 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): N/A Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Two years total: 90,000 gal.= 123 gpd.
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/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: None
Source of information:
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
_X 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:
1971
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_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: XX (locate on site plan)
Depth below grade: 8"
Material of construction:_X_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:8.5'long x 5.2'wide— 1000 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness: 3"
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: STICK WITH HINGE FLAP.
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 has previously been full to top observed solids on top of outlet baffle Lipuid level was at
bottom of outlet invert.Outlet baffle is cracked and must be replaced with a PVC tee at time of repair.
GREASE TRAP: No (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.):
Page 8ofll
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
TIGHT or HOLDING TANK: No (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: No (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: No (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.):
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
_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.): Liquid level is currently 12" below inlet pipe with well defined stain line at top row of holes and older
staining to top of structure.
CESSPOOLS: No (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: No (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.):
Page 10 of 11
•
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
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.
Buckwood Drive
Water
Service
riveway
24 20
30 27
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Buckwood Drive,Hyannis
Owner: Barbara LeClaire
Date of Inspection: March 26,2007
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water
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:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A perc test will be performed prior to repair to determine groundwater elevation.
TOWN OF BARNSTABLE
OCAI'ION SEWAGE# 2<X)-7'`��
€-ILLAGE C'1T(J-.��;:'. ASSEtSSOR'S MAP&PARCEL ` 12- kW
INSTALLERS NAME&PHONE NO."kAt_ 1oi5�xc�kic v, - 7-7 i- RZ0A
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) X 3r)Al,
NO.OF BEDROOMS Z.
OWNER
PERMIT DATE: (,= 20 -G7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY Qtx,, C � �[ ;nt+rri'nrr
O
60
tr'
i
�3R!
Q
r
INS
TOWN OF BARNSTABLE
LOCATION -'1 ,CJgcA4300d SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT AX7 —/OU
INS AME&PHONE NO. f�
SEPTIC TANK CAPACITY
LEACHING FACILrFY: (type) r-`'�`' (size)
Nip
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: of-'s COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
l
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE MARKED WITH
TOP FNDN. AT EL. 66.3' MAGNETIC TAPE OR SIMILAR FOR FUTURE LOCATION NOTES rc� �oG Q
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) 1. DATUM IS APPROX. NGVD
ACCESS COVER TG WITHIN 3" OF FIN. GRADE o
ACCESS COVER (WATERTIGHT) TO n
lb
WITHIN 6" OF FIN. GRADE 65.0 2. MUNICIPAL WATER IS EXISTING co
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM
64.8' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. �� Locus v ��
FOR FIRST 2' OR GEOTEXTILE FABRIC o
EXISTING 1000 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
GALLON SEPTIC * TEE \ o a
TANK** 63�54 I a•sum 62.0' H- 10
BAFFLE 61.52' ocoo 61.35' D 0 0 0 O D D 5. PIPE JOINTS TO BE MADE WATERTIGHT.
61.2' DDDD D DDDD
6" CRUSHED STONE OR MECHANICAL 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH Route 28
D D D D D D D D D MASS. ENVIRONMENTAL CODE TITLE V. s�
COMPACTION. (15.221 [2]) 2' D D D D D D D D D o 59.2
DEPTH OF FLOW = 4 r / 00o p
7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE_ o
INLET DEPTH = 10„ BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
OUTLET DEPTH = 14" ( 10% SLOPE) ( 1 % SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. Q
FOUNDATION EXIST. SEPTIC TANK 18' D' BOX 17' LEACHING 5' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED LOCUS MAP
FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION NOT TO SCALE
OBTAINED FROM BOARD OF HEALTH.
10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING ASSESSORS MAP 272 PARCEL 100
*THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. SEPTIC TANK DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION
LOCATIONS OF ALL UTILITIES AND ALL SIZE AT 1000 GALLONS AND ITS SUITABILITY FOR BOTTOM TH 2 EL. 54.2' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO
BUILDING SEWER OUTLETS AND ELEVATIONS RE-USE LOCUS IS WITHIN FEMA FLOOD ZONE C
PRIOR TO INSTALLING ANY PORTION OF COMMENCEMENT OF WORK.
SEPTIC SYSTEM 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
LEGEND 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
REMOVED 5' BENEATH AND AROUND THE PROPOSED
100.0 PROPOSED SPOT ELEVATION LEACHING FACILITY.
+100.00 EXISTING SPOT ELEVATION
SYSTEM DESIGN:
VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE
100 PROPOSED CONTOUR IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR SEPTIC DESIGN: GARBAGE DISPOSER NOT ALLOWED
BY HEALTH INSPECTOR
PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED DESIGN FLOW: BEDROOMS ( 110 GPD) = 2 IPD
100 EXISTING CONTOUR PROVIDE APPROX. 42' OF 40 MIL LINER AT 5' OFF SAS IN AREA SHOWN. TOP AT BENCHMARK: CORNER BY THE BOARD OF HEALTH REVISED DURING A PUBLIC USE A 220 GPD DESIGN FLOW ELEV. 62.0', BOTTOM AT ELEV. 58.0' CONC. BULKHEAD AT HEARING HELD ON NOVEMBER 15, 2005
ELEVATION 65.5' 2) FAILED SYSTEMS ONLY : SEPTIC SYSTEM COMPONENT TO SEPTIC TANK: 220 GPD ( � = 440
FOUNDATION SETBACK, IF AN IMPERVIOUS LINER IS DESIGNED 1000 rni i nil cEPTIr TANK (RF-IISF EXIST.)
AND INSTALLED (2' VARIANCE). vSE A -_--
LEACHING:
64.34 +65.12 SIDES: 2(30 + 9.83) 2 (.74) = 118
TEST HOLE LOGS b BOTTOM: 30 x 9.83 (.74) = 218
94.75,
ENGINEER: DAVID FLAHERTY, RS 10, TOTAL: 454 S.F. 336 GPD
WITNESS: DONNA MIORANDI, RS TH1 64. 4 USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR
DATE: DUNE 1 , 2007 _
6499 .16 EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5'
PERC. RATE _ < 2 MIN/INCH 65 BETWEEN UNITS
9 18, Off`
CLASS I SOILS P# 11793 . 3
TH2 i
ELEV. ELEV. ,(0 10. 65. 7 MA
APPROVED DATE BOARD OF HEALTH
0" 4 65.0' o„ 4 65.2' I s5. SH W
EXIST. DWELL.
A A TOP FNDN = +63.91
LS LS I F.a6 5 66.3' TITLE 5 SITE PLAN
lOYR 3 2 a fN�
10" / 12" B 1OYR 3/2 �? o OF
B 65.13 7 25
LS LS DECK5' 65.32 wArER��93 6 . 4 U 45 BUCKWOOD DRIVE
1 OYR 5/6 5.73 NE
35" 10YR 5/6 62.3 , +65. 8 Pq HYANNIS
34" 622
�D DRIVE U
4 1 +63.60
F fNCE 4 m PREPARED FOR
C C .33 ��
PERC BORTOLOTTI CONSTRUCTION/
65.28 B. LeCLAIR
MCS MCS LOT 39 6�
93.46' 10,007f SF JUNE 11 , 2007
2.5Y 6/4 2.5Y 6/4 63.47
_ �A OF off 508-362-4541
�0\'SN OF PigsS�C SCy fox 508 362-9880
o� ARNE H yes ARNEH.
GNm
� OJAL
16 o OJALA Cn down cope engineering, in c.2 . . CIVIL No.26348No. 307 2
� Cl l/IL ENGINEERS
NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' �o �F �o i aE ��P
LAND SURVEYORS
E P. P.L.S.OJALA, 939 Main Street - YARMOUTHPORT, MASS.
0 10 20 30 40 50 FEET DAT
07-105
07-105SP(SBO)