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HomeMy WebLinkAbout0108 BUCKWOOD DRIVE - Health lU8`131J I� j i TOWN OF BARNSTABLE LOCATION �� �� Dr.SEWAGE# � e S ('7 . VILLAGE ASSESSOR'S MAP&PARCEL ZY)-,Zj INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (size) (type) ) Za, a NO.OFBEDROOMSQC *,nn 3 OWNER PERMIT DATE: Q(( COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 07 't 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 -1 O r TOWN OF BARNSTABLE LOCATION IDS BVL WMb br SEWAGE # CIq' VILLAGE N,+��n l S ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. ,,,SEPTIC TANK CAPACITY J UVU LEACHING FACILITY: (type) ��C JAR.A?4'tJ (size) 3 6e a'X/1 NO.OF BEDROOMS 3 BUILDER OR OWNER �r4/11l� lc0/1/.1r� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ' Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le ching facility) n1 Feet Furnished by 4A ikon�n 7. t'OiG 9j W � �� � Q 0 . _ r • r TOWN OF BARNSTABLE LOCATION 1 ��� a SEWAGE # VILLAGE ASSESSOR'S MAP & LO'R "'0 9'0 INSTALLER'S NAME&PHONE NO. ®--C—�� A r SEPTIC TANK CAPACITY �• ��`�C.� �C�� t� U' V LEACHING FACILITY: (type) �� ,pCe (size) t I NO. OF BEDROOMS_ �- BUILDE,R OR OWNER � I� A PERMIT DATE: f ? _COMPLIANCE DATE:� Separation Distance Between the: Maximum•Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Piivate 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 byt3 z s y � ' N -• V�0 �' ' Commonwealth of Massachusetts i Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a Lucinda Haddock ;? u- r; Property Address 108 Buckwood Drive 7P Owner Owner's Name information is required for every Hyannis ✓ Ma 02601 10-18-18 page. City/Town State Zip Code Date of Inspection X. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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 Brett Hickey10-18-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form I Subsurface Sewage Disposal System form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y 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 was in working order at the time of inspection. 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �m 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` Lucinda Haddock V Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every Y 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 �M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y 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 ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 . Commonwealth of Massachusetts �n Title 5 Official Inspection, Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El a Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Fx1 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. ❑ E] Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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. ❑ Q 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 260 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 l5insp.doc•rev.706/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �m l Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock V Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ R 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? ❑ ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Q Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? E ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑7 O 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owners Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 2 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 349/gpd Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Does residence have a water treatment unit? ❑ Yes ro No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes (E No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***2016-20,196 gallons 2017-17,204 gallons*** Sump pump? ❑ Yes ❑■ No "s Last date of occupancy: 1 weekDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock V Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- pumped within the last year Was system pumped as part of the inspection? ❑ Yes X 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 �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System'Information (cont.) 4. Type of System: El 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: 1999 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 11311 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 6. Septic Tank(locate on site plan): 311 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 1000 gallon Dimensions: 611 Sludge depth: 3091 Distance from top of sludge to bottom of outlet tee or baffle 1 rr Scum thickness 691 Distance from top of scum to top of outlet tee or baffle 15111 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, in and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. 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 0 Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA 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 4n Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock v Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y 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): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/262018 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 Lucinda Haddock v� Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y 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.): NA " If pumps or alarms are not in working order, system is a.conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 36'X2'X11'W/4 infiltrators 0 leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every 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.): The leaching was in working order and was dry with no high staining at time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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 �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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 Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y 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: M hand-sketch in the area below ❑ drawing attached separately PM M � x�� r, t G 9Fa' i E' Oa �, •r - -era/,A SAS ERa` J GfaidwM t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar 0 Shallow wells No GW @ 27' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record Installer information sheet 8-20-95 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. 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 I c Commonwealth of Massachusetts +n 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lucinda Haddock Property Address 108 Buckwood Drive Owner Owner's Name information is Hyannis Ma 02601 10-18-18 required for every Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusettsgal Title 5 Official Inspection Formcopy Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information is required for Hyannis MA 02601 December 7,2010 every 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. Important: A. General Information _ When filling out forms on the ll computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name Y� P.O. Box 371 Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-6055 SI 12843 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 December 15, 2010 1 Inspector'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 j6r 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. agelt5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage isposal of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information required for rts Hyannis MA 02601 December 7,2010 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: 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 completioq�.of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined , N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years of or the septic tank(whether metal or not) is structurally unsound, exhibits substantial in ration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is r placed with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. ❑ Y ❑ N ❑ D (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information is required for Hyannis MA 02601 December 7, 2010 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 higji static water level in the distribution box due to broken or obstructed pipe(s) or due to a brok , settled or uneven distribution box. System will pass inspection if(with approval of Board of H alth): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): A ❑ distribution box is leveled o 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 ❑� ❑ N ❑ ND (Explain below): C) Further Evaluation is Req/plic he Board of Health: ❑ Conditions exist which requevaluation by the Board of Health in order to determine if the system is failing to protealth, safety or the environment. 1. System will pass unlef Health determines in accordance with 310 CMR15.303(1)(b)that the systenctioning in a manner which will protect public health, safety and the environme ❑ 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•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information required for rirts re4 Hyannis MA 02601 December 7, 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 a orption system (SAS) and the SAS is within 100 feet of a surface water supply or t ' utary to a surface water supply. ❑ The system has a septic tank and SA and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS a d 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 wat analysis, performed at a DEP certified laboratory,.for coliform bacteria indicates absent and the p sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no her 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 4 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �vtj-, 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information i ls Hyannis MA 02601 December 7, 2010 eery 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. ❑ ® Anyportion 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. 1. 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 wit ' 400 feet of a surface drinking water supply ❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syste s located in a nitrogen sensitive area (Interim Wellhead Protection Area I PA) or a mapped Zone II of a public water supply well If you have answered "yes" o any question in Section E the system is considered a significant threat, or answered"yes" in Se . n D above the large system has failed. The owner or operator of any large system considered a si ificant threat under Section E or failed under Section D shall upgrade the system in accordan ith 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yy< 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information is Hyannis MA 02601 December 7, 2010 required for y every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ 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): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 340 GPD t5ins•09/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name r f urired forts Hyannis MA 02601 December 7, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 2009=64 GPD g ( y g (9Pd))' 2010= 53 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 itle 5 system? ❑ Yes ❑ No Water meter readings, if availabl t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information Is required for Hyannis MA 02601 December 7, 2010 every 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: Ready Rooter records: pumped 10/31/08 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �y 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information is required for Hyannis MA 02601 December 7, 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: Septic tank installed late 1970's. D-box and SAS installed 08120/1999. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 102"feet Material of construction: ❑ cast iron ❑ 40 PVC ® other(explain): Orangeburg Distance from private water supply well or suction line. N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Recommend replacing orangeburg sewer line. OK at time of inspection. Septic Tank(locate on site plan): Depth below grade: 4"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: 8.5'X 4.5'X 4.5' 1000 gallons Sludge depth: 3" t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name required information for Hyannis MA 02601 December 7, 2010 every 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 32" 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 13" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet PVC tee in place. Liquid level at outlet invert. Tank pumped and cleaned after inspection. Recommend pumping every two (2) years. Grease Trap (locate on site plan): Depth below grade: /� feet Material of construction: r ❑ concrete ❑ metal /X1 fiberglass ❑ polyethylene ❑ other(explain): I Dimensions: Scum thickness Distance from top of scu/mtpo utlet tee or baffle Distance from bottom of om of outlet tee or baffle Date of last pumping: Date t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yy< 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information oulred for r Hyannis MA 02601 December 7, 2010 e e. City/Town State Zip Code Date of Inspection every page. D. System Information (coat.) 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 ❑/erglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: f , 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 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name requiredinformation ls Hyannis MA 02601 December 7, 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 oil 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.): One inlet, one outlet. No solids carryover. No sign of high water staining over outlet invert. No sign of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pum/amber, ndition 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 Forth:Subsurface pecti Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name y formation is Hyannis MA 02601 December 7, 2010 squired for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-H/C infiltrators w/stone. ❑ 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.): Camera used to locate and inspect SAS. No sign of past 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 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwat inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name required information ls Hyannis MA 02601 December 7, 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 conditio f 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 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information is required for Hyannis MA 02601 December 7, 2010 every page. Cityrrown 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 i \ I I I I 1 r 1J 3 • ` � 3 as i t5ins•osroa Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information is Hyannis required for MA 02601 December 7, 2010 every page. Cityrrown state Zip Code Date of Inspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 27+- 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: 08/20/1999 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Emergency repair of SAS shows ground water 27'+-from base of SAS(1999).Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 16 of 16 I i L Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Buckwood Drive Property Address Walter Fandel Owner Owner's Name information required for irts re9 Hyannis MA 02601 December 7, 2010 every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 17 of 17 r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP - Z? PARCEL � ®`a 2- LOT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 108 Buckwood Drive Hyannis, MA 02601 Owner's Name: Janice Leonard Owner's Address: Date of Inspection: February 11, 2004 Name of Inspector:(Please Print) James M. Ford ��D Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 [FEB 2 6 2004 Telephone Number: (508) 862-9400 TOWN OF BARNSTABLE HEALTH DEPT. 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: February 14, 2004 The system inspector shNsubmia 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 i ****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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 108 Buckwood Drive Hyannis, AM Owner: Janice Leonard Date of Inspection: February 11, 2004 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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 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 forma 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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 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)]. i 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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): 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): 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: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--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/Altemative 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: Installed 8120199-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: 108 Buckwood Drive Hyannis, AM Owner: Janice Leonard Date of Inspection: February II, 2004 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: 3" 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: S" 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 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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 4 high capacity infiltrators 36'x 2'x 11'(per as built card) 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.): There did not appear to be any signs of failure from the leach field. The bottom to grade was approximately 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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 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. LA Q a O 3 3 y ya y3 , 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: 108 Buckwood Drive Hyannis, MA Owner: Janice Leonard Date of Inspection: February 11, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- 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 the Barnstable topographic map and water contours map the maps were showing 30'+/-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 i / N �76 /it CA WX 0\,, 34 42 �� N e �.- 'r7 � 586 D6DD s6. 3j87 -- 92.49 6 21' l6"� � 9 A % � OO to r CcAj �d p L � p Dndew - r a r 89° 6' 2. 63 4/.6'7 C.D. S 76 E s�45 0 O 32 O m c ' ' 46 OV 6V m 122. 67 31 N 76° 3¢' 40„ W 5 Subdivision of Lots 2,3 and 4 Shown on Plan 35404A Sheet 1 Filed with Cert. of Title No. 42b23 Registry District of Barnstable County i Separate certificates of title may be issued for land shown hereon as�o}sg2_t�fy_�6___________-__-__ BY the Coart_ Copy of part of p/a NO. Fee THE COMMON-WEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE MASSACHUSETTS YV ., Zipplication for Migosml *p6tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Abdividual Components Location Address or Lot No. too G Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��])_O F+� % G-c k W Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Etc,S j IC J Type of S.A.S. Rv ,Vk Description of Soil p" , cS Nature of Repairs or Alterations(Answer when applicable) ;T_(ti9 do Ca nG,G �`GI,G?'cc� Cr✓ Yw�7/✓LS �. , �(( STD Ctu� S, nor - ���/ C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with thed not to place the system in operation until a Certifi- cate of Compliance has been iss d by this Boar th. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. —.$�� Date Issued F`f 9 ti 9 i ai z No. / S / Fee �� ' THE COIFAM®fAVEALTH OF MASSACHUSETTS Entered in computer: v Y "' :PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Rpplication for ligpoml *pgtem Cowaruction Permit--. Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System Avdividual Components Location Address or Lot No. i Q8 C Owner's Name,Address and Tel.No. Assessor's Map/Parcel ;)—�C')_O Fc�— 1 j G;,-6 W l C- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ry\l0-C, S C \ �\ S ���c Sc 4 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 �, gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Fk-, S:II �� k Type of S.A.S. : C_ (",,7- ,- T L.. Description of Soil s W Nature of Repairs or Alterations(Answer when applicable) 4t c, l 7 -Tcc_,��L:�bf i-fi r2 S �t �`{c�2'9 l9 Q, 42�-- r ,r T Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisirgTs-o -Tittr5vf4be ifenmen+al-Gode_and not to place the system in operation until a Certifi- cate of Compliance has been issued,by this Boar th. Signed .-- _--'' Date q Application Approved by Date Application Disapproved for the following reasons Permit No. —S/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance s THIS IS TO CERTIFY,that the On-site Sewage Disposal S stem Constructed( )Repaired( )Upgraded Abandoned( )by _ 1 l� = Cr at 15 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pen6it No. dated Installer Designer . The issuance of this permit shallhe—construed as a guarantee that th"•st 1 function des' d. Date � a ~" Inspec(Gr, No. J / Fee J �! THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Iigpogar *pgtem Congtruction Vermit Permission is hereby granted to Construct( )Repair( )Upgrade((��Abandon System located at , and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this it. S � Date: �"// Approved by �• .,a 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, o✓ hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at V6- —Ln� . Cn DJ meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business / uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system c� There is no increase in flow and/or change in use proposed There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the ma�dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] if the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 1� B) G.W. Elevation Solo+the MAX High G.W. Adjustment DIFFERENCE BETWEEN A and B J l SIGNED : DATE: [Sketch proposed pl of system on back]. q:health folder.cent r � � �_ �� �, ---�. f TOWN OF B,A(�RNSTABLE LOCATION , �'� '�� `�"�0 SEWAGE # I VILLAGE ASSESSOR'S MAP & LOt? "0 F'? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c LEACHING FACILITY: (type) �� ti,�C4`t-, �t (size) NO. OF BEDROOMS a BUILDER OR OWNER `(�Jk A-�J PERMITDATE: 4 1-7 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 c Furnished by �� TT -7-e- T� �zH i