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0145 BUCKWOOD DRIVE - Health
145 Buckwood Drive Hyannis. F 'P A 272 086 � � o i I� � a lip I� R 1 o TOWN OF ARNSTABLE LOCATION goo /l., SEWAGE VILLAGE ASSESSOR'S-MA6P S_c ARCEL '� INSTALLERS NA LE&PHONE NO. 01, VIC� 4_ 4F&) CL SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (. ) e / /size T J NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge,of Wetland and Leaching Facility(If any wetlands exist within 300.feet of leaching facility) Feet FURNISHED BY ti V-3 e e t jp) Y r i i s 009 o� R 'No. Fee 'SHE COMMONWEALTH OF MASAACHUtiETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEi MASSACHUSETTS Yes Zipplicatton for �DigpOgaY 6pgtem Co gtructiun Permit Application for a Permit to Construct O Repair O Upgrade O Abandon O ❑Complete System ❑Individual Components Location Address or Lot No 2Z2 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,A ress,and Tell No. Designer's Name,Address and Tel.No. Type of uilding: 3 �� Dwelling No.of Bedrooms `f �otJSize sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _30 gpd Design flow provided �� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) y�� —�-t' �/ �C�lj 7,-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 provisions of Title 5 of the Environme Cod and not to place the system in operation until a Certificate of Compliance has been issued by this Board o ealth. Signed Date 3 - a�^41 Application Approved by Date 3 Application Disapproved by: Date for the following reasons Permit No. d 6 ,— O Z Date Issued 3` a �� _ r.-.,�.,,s._�. t. .., .,.. f ...�_-._..-_..-•_---^---r.ti. �y _._— ,. --�*',r,;r .-w:. .wt .� _,ter _-.-`.. . .. .....;,:.. . -.- aoo8 !�6 .`- �v No. . ; .. � *� t. � Fee T --COMMONWEALTH OF MAS C'll•IUSETTS Entered in computer: PUBLIC HEALTH:DIVISION TOWN OF BARNSTABLE MASSACHUSETTS Yes Zipplication for Mt!6poal *pgtem Con5trUction Permit Application for a Permit to Construct O Repair( ?) Upgrade O Abandon(') ❑ Complete System 0 Individual Components Location Address or Lot Ng. v� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 6 f Installer's Name,Address,and Tel..No. Designer's Name,Address and Tel.No. Type of uilding: P : / ob Dwelling _ No of Bedrooms QP( 514 6t Size sq.ft. Garbage Grinder ( ) Other Type of Building /rwJ _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures _ Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank — Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /j// /� �!( O��/9G Zj,.y,� Date last inspected: 4 Agreement: v The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme.tal Co sand not to place the system in operation until a Certificate of Compliance has been issued by this.Board o ealth. ned D 3 Si O r, g '' - ate Application Approved by Date 3' Application Disapproved by: Date for the following reasons Permit No. d C U Date Issued 3 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, hat the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( )by Oat � � p � � has been constructed in accordance with the provisions o Title 5.and thejg�Disposal System Construction Permit No. g Oy g , /06 dated 3 1 p Installer +7� ? _ De igner Q- I V 1 #bedrooms v!1�, f 44trs Approve4a ,,,n,flow , gpd The issuance of this pedrtY�t sh 1 not be construed as a guarantee that the systeu ction as designed. 'jDate Ins ecto .. , v v yr v ip v v yi yr•'✓t —————————————————————————————————— ———————— No. a 00 $-101fo Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS wi!6po5ar �&p5tem Co�n"!Atr dion Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at I-,(c �_,F'(u,r Ly_ 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 pEerwi� 3- ao - o � Date Approved by " Town` of Barnstable CF tHE 1p� Regulatory Services Thomas F. Geiler, Director BARNSTABLE, 9 MASS. g Public Health Division A'F1639. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 4/02/08 Designer: _Shay Environmental Services, Inc. Installer: Rodney Fisher Address: P.O. Boxi627 Address: SK Kelley Street _ East Falmouth, MA 02536 Harwich, MA On 3/22/08 _Rodney Fisher was issued a permit to install a (date) (installer) septic system at 145 Buckwood Drive, Hyannis, MA based on a design drawn by (address) _Shay Environmental Services, Inc. dated_March 19, 2008 (designer) _XX I certify 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 with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the se ) but in accordance with State & Local Regulations. Plan revision or certifi as-built b designer to follow. OF 4 GAMF talle Signature) " g tL_ 11F�1 F�lST�� iv S \F'� esigner's Signature) (Affix Desig p 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: Health/Septic/Designer Certification Form Town of Barnstable P# Z2/5- 3 lime Department of Regulatory Services 1 z DARN91AREAi Public Health Division DateHJUM 63P a�� 200 Main Street,Hyannis MA 02601 AAKt Date Scheduled Time 4!5�� Fee Pd. �� Soi uitability Assessment for Sewage Disposal Performed By: � Witnessed By: LOCATION&GENERAL INFORMATION Location Address Owner's Name nn Address . Assessor's Map/Parcel: o(7 C)$ Engineer's Name( 7��� NEW CONSTRUCTION ON / Telephone#. [J Jq -}q LQ(V Land Use.- 2me—, Slopes(46) Surface Stones Distances from: Open Water Body $ Possible Wet Area ft Drinking Water Well A)1A --ft Drainage Way n r g Y ft Property Line o[S ft Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to holes) t Is L v �t�sT boast; V`i s �uGlsweo�r `�Q.\vim Parent material(geologic) yU'1-'Clsr\ Depth to Bedrock Depth to Groundwater. Standing Water in Hole: r�on - 2kp Weeping from Pit Foce � `2 6bS, Estimated.Seasonal High Groundwater DETERNHNATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to soil mottles: In, Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well levei -, Adj,factor, ,>� Adj.Croundwater Level Observation PERCOLATION TEST Date31151 Tnta t0,c,3A11-\ Hole# Time at 9" Depth of Perc °t.��� ? Time at 6" + i1 Start Pre-soak Time @ i ob Time(9"•6") (Om 1 o ';,(' End Pre-soak r Rate MinJlnch �_ ---r-� y , Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 1 00'of wetland,you must first notify the Y Y Barnstable Conservation Division at least one(i)week prior to beginning. Q:ISEPTICIPERCFORM.DOC f t DEEP.OBSERVATION HOLE LOG Hole# #I Depth from Soil Horizon Soil Texture .Soil Color Soil Other- Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistengy, ravel © -(P Jl- 1CN2 317, k -fie. A MPA SmA . Y a DEEP OBSERVATION HOLE LOG Hole# "Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, J L1 J • � �Cobb� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C i to vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (MUTMII) Mottling (Structure,Stones,Boulders. on Flood Insurance Rate Man: Above 500 ear flood boundary No— Yes - Within . Within 500 year boundary, No Yes t Within 100 year flood boundary No✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? ..�., Certi_ fication I certify that on \0 0 (date)I have passed the soil evaluator examination approved by the M Department of Envir mental P tection and that the above analysis was performed by me consistent with . the required traini g,a rti a rience described in 310 CMR 15.017. ,p Signature Date 3 v Q:VSEPnCVERCFORM.DOC Town of Barnstable �1HE Tp� Regulatory Services , RrnsLe ; Thomas F.Geiler, Director Atfp�.�A 16 9. ••� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 31, 2007 David Holt Today Real Estate 1533 Falmouth Road Centerville, MA 02632 Re: 145 Buckwood Drive ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 145 Buckwood Drive, Hyannis, MA was last inspected on May 21", 2007,by Michael DeDecko, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: 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 HEAL H DEPARTMENT ma A. cKean, R.S., C.H.O. Agent of the Board of Health _ G_ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments K— M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name rQ P.O. BOX 2384 Company Address MASHPEE MA 02649 ' O Cityrrown State Zip Code 508-221-5003 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 ►.a r� -ti: 5/21/07 -:i N Anspctors Signature Date Q1 ; The system inspector shall submit a copy of this inspection report to the Appr'ving AuTority,;(Board of Health or DEP)within 30 days of completing this inspection. If the system ic a sharpA system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall gubmit4he report to the appropriate regional office of the DEP. The original should be sei it to the sy+sterrrowner 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. 26 AGAWAM LAKE SHORE DR•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Lb Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is HYANNIS MA 02601 5/21/07 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 26 AGAWAM LAKE SHORE OR-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 26 AGAWAM LAKE SHORE DR-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is HYANNIS MA 02601 5/21/07 required for every page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: N/A 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: Last date of occupancy/use: Date Other(describe): 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is HYANNIS MA 02601 5/21/07 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, yes vented, no sign of leakage. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No - - - - - - ----------------------------------------------------------------------------------------------- Dimensions: 1000 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is HYANNIS MA 02601 5121/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): need to pump, tee's intact, structurally sound, liquid level equal with outlet invert, no 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 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): 26 AGAWAM LAKE SHORE DR•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < ^M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert equal with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is level and distribution is equal, yes solid carryover, no signs of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is HYANNIS MA 02601 5/21/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil sand/gravel, yes sign of hydraulic failure, ponding 4% yes damp soil, vegetation overgrown. i 26 AGAWAM LAKE SHORE DR-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is HYANNIS MA 02601 5/21/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 26 AGAWAM LAKE SHORE DR-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • �,M 145 BUCKWOOD DR Property Address p Y C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. z 3 .23 R 1,2 26 AGAWAM LAKE SHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i . Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 145 BUCKWOOD DR Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 5/21/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 60' no water feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: town of barnstable gis shows spot elevation at 63.39 26 AGAWAM LAKE SHORE DR-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 2-) 4-3L - _COMMONTEi� I zi OF MASSAC-IMSETTS EXECS OFFICE OF ENVIRONWEN-TAL AFFAIRS :DEPARTMENT OF ENVIRONMENTAL PROTECTION i IVE-D y e j - 3 2005 ABLE TITLE 5 PT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOkM PART A CERTIFICATION Property Address: 1 4L '.CU2.� ,.OT Owner's Name: Owner's Address: l ', _SUc. woo& 1>r"We r W: Date of Inspection: t off• ll f-Tn Name of Inspector: please print) i 4 e f = Company Name: i evL Ong pec..�Cu.�,si Mailing Address• 6 Telephone Number: 510a•5 7606 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.1 am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: / Date: 42 pj&v 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 ****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 `6/152000 page I Page 2 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IRSPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• aUO t Owner. p9 Date of Inspection: Inspection Snmmary: 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" on need to be replaced or repaired.The system,upon completion of the replacement or repair,as appro by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the fol ing statements.If`not determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic as approved by the Board of Health. *A metal septic tank will pass inspection if it is sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o i5 available. ND explain: Observation of sewage b p or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a settled or uneven distribution lox.System will pass inspection if(with approval of Board of Health} broken pipe(s)am obi isumoved distribution lox is leveled or replaced ND explain: The m required pumping more than 4 times a year due to broken or obstructed pq*s).The sy3n:m will { pass insp on if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /y r Owner: Cd Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which equine further evaluation by the Board of Health in order to dete a 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 R 15303(1)(b)that the system is not functioning in a manner which will protect public health,saf 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 wed or a salt marsh 2. System will fail unless)be Board of Health(and Publ' Water Supplier,if any)determines that the system is functioning in a manner that protects the pub health,safety and environment: _ The system has a septic tank and soil absorp ' system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface w r supply. _ The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. . — The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Me d used to determine distance *"This system passes if the w I water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile-organi compounds indicates that the well is free from pollution from that facility and the presence of ammonia itrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trio° red_A copy of the analysis must be attached to this form. 3. Other: i 3 1 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOISAL SYSTEM INSPECTION FORM PART_A- CERTIFICATION(continued) Property Address: U Ue 00al 1,k- .-,76 _ Owner. Date of inspection: y D. System Failure Criteria applicable to all systems: You mast indicate"yes"or"no"to each of the following for ail 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 m 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 - Required pumping more than 4 times in the last year N07C 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 cnWorm 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 5ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] A(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 316 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to deteramie what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve.a fac design flow of 10,000'gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the fo (The following criteria apply to large systems in ad ' oa to the criteria above) yes no the system is.within 400 feet a surface drinking water supply the system is within 2 eet of a tributary to a surface drinking water supply the system is 1 in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Hof a ' lie water supply well If you have answ ed"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in S D above the large system has failed.The owner or operator of any large system considered a significan under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. a system owner should contact the appropriate regional office of the Department. � A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: C o Dell�►� Owner. Date of Inspection: 4 (—�_ Qd Check if the following have been done.You must indicate`eyes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health Were any ofthe system components pumped out in the previous two weeks? — Has the system received normal flows in the previous two week period Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system obtained and examined?(If they were not available note as NIA) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? — Were all system components,excluding the SAS,located on site? I _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 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 D—�- — Existing information.For example,a plan at the Board of Health. Determined is the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CN. M 45302(3)(b)J t S Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: l kA— Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3_ Number of bedrooms(actuaI): _ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no): Ab Is laundry on a separate sewage system(yes or no): AZ[if yes separate inspection required) Laundry system inspected(yes or no):jM Seasonal use:(yes or no): . Water meter readings,if available(last years usage(gpd)): 0% Sump pump(yes or no): //11;+�� Last date of occupancy: C L)(, COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): opd Basis of design flow(seats/persons/sq ): Grease trap present(yes or ao): Industrial waste holding tank ent(yes or no): Non-sanitary waste disch d to the Title 5 system(yes or no): Water meter readings i available: Last date of occu cyluse:s OTHER( tribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part;of the inspection(yes or no):A�LO If yes,volume pumped:: gallons—How was quantity pumped determined? Reason for pumping: T,YfE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes(or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval `Other(describe): Approximate Ige of all components,date installed(if known)and source of information: c7 tA 0 . Were sewage odors detected when arriving at the site(yes or no):P D 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE;SEWAGE DISPOSAL SYSTEM[ INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: G d Owner: ConAz . Date of Inspection: \ o 2110 �>! BUILDING SEWER(locate on site plan) . tt Depth below grade: Q Materials of construction: cast iron Y40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_X_(locate on site plan) Depth below grade: Material of construction: a oticrete_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: LQO p G'a t Sludge depth: tt Distance from top of slucae to bottom of outlet tee or baffle: o2a Scum thickness: Distance from top of scum to top of outlet tee or baffle: _ C Distance from bottom of scum to bottom of outlet tee o baffle: _ How were dimensions determined:_ (� 'eAsurea Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, e ` GREASE TRAP:,(locate on site plan) Depth below grade:_ Material of construction: concrete imetaI berglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of tlet tee or baffle: Distance from bottom of scum to ttom baffle:of outlet tee or bae: Date of last pumping: Comments(on pumping endations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inve 'dense of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l q5i gu& rQ Owner: Date of Inspection: taL 04-1"Y TIGHT or HOLDING TANK: (tank must pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(owlain): Dimensions: Capacity: Ions Design Flow: allons/day Alarm present(yes or no . Alarm level: arm in working order(yes or no): Date of last pump' Comments(con ' on of maim and float switches,etc.): DISTRIBUTION BOX: sue . (if present must be opened)(iocate on site plan) Depth of liquid level above outlet invert G WA Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or ut of box,etc.): / •� bax � � fetJCl 44r PUMP CHAMBER: {locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or Comments(note condition O 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: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type D� leaching pits,number. leaching chambers,number. leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. innovative/altetnative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): l e / f O wt Q n C- CESSPOOLS: (cesspool must be pumped art 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 groundw r inflow(yes or no): Comments(note co ition 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 co ition 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: GL�pg� Owner: Cob 0. Date of Inspection: It ;�i k&(oO 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. 1 7 33 o'Z Gv 2 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ny,S`, Owner: Wte of Inspection: SITE EXAM Slope 00 Surface water VJO Check cellar 1��5 Shallow wells bQ0 Estimated depth to ground water; 6-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 propertylobservation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-ezpiavn: You must desS be how you!established the high ground water elevatio ll COMMONWEALTH OF MASSACHUSETTS ExECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONNtNTAL TR,OTECTI � �, _ �°°�,� T00 tiFo,� & leaO `TITLE 5 _ <0 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S ,✓ SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A fry CERTIFICATION MAP �.,_...� Property Address: `f S �vclTGr/o a® 41411,9 PARCEL Owner's Name: 1rZ*6A g/y LOT Owner's Address: 5.4-3 Date of Inspection: Flame of Inspector: (pleaserprint).��fJy-.�.� /1i2��,4s�i3c'.9-I /T Company Name:Mailing Address: n d f3 air �'!1 ,f Telephone Number: -5-i3 d 4 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 toSection 15-W of Title 5(310 Cli�.15.000). The system: ' Passes Conditionally Passes Needs Further.Evaluation by the Local Approving Authority Fails Inspector's Signat ire Date. zS The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or 4_ DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow o€10,{000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection-does not address how the system will perform in the.future under the same or different conditions of use. I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: e o of A2 i v� 1v J- Owner: Date of Inspection: inspection Summary: Check A,B,C,ID or E[ALWAYS complete an of Section D =Systemund any in"fomnation which indicates that any of the failure criteria described in 310 CAT 15303 or in 310 CMR,15.3K exist.Any failure criteria not evaluated are indicated below. Comments: T l B. System Conditionally Passes: - One or more system components as de bed in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the lacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in th forthe folio ' g statements.if"not determined"please explain. The septic tank is metal and over 20 years o d*or septic tank(whether metal or not)is structurally ' unsound,exhibits substantial infiltration or exfil 'on tank fail is imminent.System will pass.inspectics ifthe existing tank is replaced with a complying septic approved by she Board of'Health. *A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance indicatingthat the tank is less than 20 years of av ' le. ND explain: Observation of sewage backup r break but cr ' static water.level in the.distributian.l ox.due to bm or; obstructed pipe(s)or due to a brok settled or uneven button box.System will pass.inspection if(with approval of Board of Health): broken pipe(s)are rep . ed obstruction is removed. distribution box is orreplaced. . ND explain: The system requir pumping more than 4 times a year due to.broken or obstrwed pipe(s).The system will Pass inspection if(with praval_of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 — —---. - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. . — — SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F®ItIVi PART A CERTMCATI®let continued Property Address: Owner. 114. • r� �,r�e g Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluatio by the Board of Health in order to determine if the system is failing to protect public health,safety or the enviro rient 1. System.will pass unless Board f lth determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a nner which will protect public health,safety and the environment: _ Cesspool or privy is in 50 eet of a surface water _ Cesspool or pri s within 50 t 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 heal h;safety and environment: _ The system has a septic tank and soil absorption in(SAS)and the SAS is within 100 feet of a surface water supply or tributary 'a surface wat upply. The system has a septic tank d SAS d the SAS is within a Zone I of a public water supply_ — The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and AS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod d to determine distance "This system passes if a well water alysis,performed at a DEP certified laboratory,for coliform bacteria and volatile o 'c compounds dicates that the well is free from pollution from at c'Po p that facility and the presence of am ma nitrogen and ni a nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are 'gg;r d.A copy of the alysis must be attached to this form. 3. Other: Page 4 of I} - OFFICIAL INSPEC1710N FOR -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEKINSPECTION FORM PART A CERTIFICATION( ) Property Address: Owner.• Gf ,�� ,g 2� ' Date of inspection: a' a 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 surfacewaters 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 Acesspool Liquid depth in cesspool is less than bbelow invert or available-volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface _ / water supply. .Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion ofa ces�or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water-quality analysis.['Phis system passes if the well water analysis, performed at a DEP certified laboratory,for conform bacteria and volatile organic compounds indicates that the well"isfree from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or bw than:5 ppan,provided that no other&du=cAftyi2 are triggered.A Copy of the analysis mmt bL,2Mched to-this brin.1 (YeslNo)The system fails.I have deter that one or more of the above ire criteria exist as described in 310 CMR 15.303,therefore the system fails:The system owner.shoild contact the Board of Health to determine what-will be necessary to correct the failure. E. Large Systems: To be considered a large system t sg�stemrtafacilit§'wa design:ifloww of 10,000 gpd to I5,000 You must indicate e' "yes"or "to each of the following: (The following crit apply to l e systems in addition to the criteria above) yes no _ the system is wi 00 feet of a surface drinking water supply _— the system is 00 feet of a tributary to a surface.drinking water supply — — the system is 1 ted a nitrogen sensitive area(Interim Wellhead Protection Area.-IWPA)or a trapped Zone II of"a blic w 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 der Section D shall upgrade the stem in accordanc e with 310 CMR significant threat under Section E-or failed under pgrad system 15304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - -- PART B CHECKLIST Property Address•��S UG�G�oo�vGl/Ut Owner: 'rl,i, Date of Inspection: Check if the following have been done.You mast 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? L _ 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 f _ Was the site inspected for signs of break out? I _ 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 o�f tthe baffles or tees,material of construction,dimensions,depth'of liquid,depth of sludge and depth of scum? l _ 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 Iocation of the Soil Absorption System(SAS)on the site has been determined based on: 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 Cis at issue approximation of distance. is unacceptable)(310 CMR 15.302(3)(b)j Page 6 of"I I ---- OFFICUL INSPECTION FORM-NOT FOIL=VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-D]M'OSA'L-SYSTEM-IlKSFEC'ON FORM PART€ SYSTEM-INFORMATION Property Address:/Gl4i o e d1�v� Owner: - Date of Inspection: a a FLOW£ONDMONS RESIDENTIAL Number of bedrooms(desigp):— _Number of bedrooms(actual) DESIGN flow based on 310 CMR 15.203(formcample:110.gpd x#Dfbedrooms} J Number of current residents: Does residence have.a garbage grinder-(yes-or no): Is laundry on a separate sewage system yes or-no):7/ lif yes separate-inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gp d})�d�/ ;l�Qo G t- a Sump pump(yes or no): ; Last date of occupancy: //d a.) COMMERCTAL/INIDUSTRIAL Type of establishment' - Design flow(basedA 15.203): gpd ------- Basis of design floons/sgft,etc.): Grease trap present _ Industrial waste holesent(yes or no):_ Non-sanitary wasteo the Title 5 system(yes or no): Water meter read' le: Last date of occ ancy/use: OTHER(describe): GENERAL7NFORXATI0N Pumping Records Source of information: Al k W-as system pumped-as part of the inspection(yes orno): €S Ifyes,volume pumped/ e edaste, -&erind?-//2- Reason for pumping: R X -A s s / TURF-SYSTEM _ f Septic tank,distribution bor,soil absorption systems a _Single-cesspool Ovverflowcessgoor- P-nvy _Shared system(yes or-no)(if yes,attar it previous inspeetiau-tecor&,,if anyy. _Innovative/Alternative technology.Attacit:a-eopy ofthe=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: Were sewage odors detected when arriving at the site(yes or no): Page 7ofII —_ — OFFICIAL INSPECTION FOMM—NOT FOR VOLUNTARY e�SESSi NTS — - SIBSLWACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property A&ress: I'V5 13�'ar Owner.G'p i i 2 0 C14.4/ Date of inspection: I31FL1 ING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron — 4 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SE MC TANK_(locate on site plan) --—-- Depth below grade: 5' Material of construction: roncrete metal fiberglass—polyethylene otha(explain) — Tf tans;is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(amwh a copy of certificate) Dimensions: x, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: "'p, Distance from top of scum to top of outlet tee or baffle:3 Distance from bottom of scum to bottom of outlet tee or baffle: Sc ry j 3�'/3 How were dimensions determined: /17 Comments(on pumping recommendations,inlet and outlet tee or baffle conditior,,structural integrity,liquid le refs as related to outlet invert,evidence oi-leak-age,et ): /� uJiv E�L /�u vh A t s%STD GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:— ncrete metal_fiberglass_polyethylene other (explain): Dimensions: S,mum thickness: Distance from top of scum to to f outlet tee or baffle: Distance from bottom of scum b ttom of outlet tee or bailie: Date of last pumping; - Comments(on pumping reccmrmen. ', ns,inlet and outlet tee or baffle condition,structural integrity,liquid lev�ls as related to outlet invert,evidence of leakage,etc.): Page 8ofti OFFICL41 INSPECTION FORM—NOT FOR VOLUNTART ASS.ESSME.NT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM EqSPECTION FORM . PART C S v-STEM RWORMAMiLON(s mmued) Prop Address:�vs- 13v��i'�voo e,Aw Owner.Ari%�, �i Tz G SA'A / Date of inspection. TIGHT or HOLDING Tom: (tam mast be pumped at ifim of ec ' tton}(locate on site putt) Depth below grade: Material of construction: concrete metal fiberglass__Folyeth �le:k oth Dimensions: Capacity. allo Design Flow: nslday A-d arm present(yes or no): Alarm level: work Cate of last pumping (yesor no Comments(condition alarm and float switches,etc.): (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert; � Comments(note if boat is level and distribution to outlets ealual,any evidence of solids carryover,any evideu�: of l:akage into or out of box,etc.): /J / �JC J 5 �E UC �i►^'U Gv/3TE GL T� / f 1 __h1P CHAMBER: (locate on site plan) Pumps in working order(y s or noj- klarms in working order(y or }: C&rr meats(dote condition of chamber,condition t'mmps and appWUnances, Page 9 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — PART C SYSTEM INFORMATION(continued) Property.Address:.f�i`'`S f3v GrrO oe Owner:Ar.�+ Date of Inspection: 6�2 SOIL ABSORPTION SYSTEM(SAS) (locate on site_plan,excavation not required) If SAS not located explain why: Type leachin its number: IL gP � _ leaching chambers,number: teachirWgalleries,numbei:I` ` - - leaching trenches,number,length: leaching fields,number;dimensions: overflow-cesspool;number. a innovative/ahernative system Typebame of technology: Conmrents(note-condition-of soil;signs-of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inve , Depth of solids layer: Depth of scum layer: Dimensions of cesspool.- Materials of construction: Indication of groundw r inflow(yes o no): Comments(note con lion of soil,signs f hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan). . Materials of construction: Dimensions: e Depth of solids: Comments-(note conditi f soil; s of hydraulic failure,level-of ponding;condition of vegetation,etc.): Page 10 of 11 - - FOR VOLUNTARY ASSESSMENTS- ' OFFICIA�INSPECTIOI�I FORM NOT O . SUR suRFACE SEWAGE_DISPOSAL_.SY=INSPECTION FORM P-ART-C- - - SYSTEM INFORMATION(continued)_ Property Address:. Owner:10k,_,1 f.?L ��•g/ - Date of-Inspection-:. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch ofthe sewage disposal system incl-udingties to at-least two permanent reference landmarks or benchmarks.Locate alfwells within-100 feet Locate where-public watersuppi"nters-the-building. G/-r B `9 L3 03 OP v -- 0 F 37 l Da0,4P ' . / f - O Ca .INSPECTION FORT a—NOT FOR VOLUN7ARY ASSESSMENTS SUBSURFACE SEWAG'E DISPOSAL SYSTEMT INSPECTION EOM — ---- PART C SYSTEM n F ORMATION(continued). Property Address: �5 .l��druio®d��R�vF �wne�': e•�, �?z r q L-ate of Inspeefiow 5- G1a SI E EXAM Slpe Surface water Check cellar Shallow wells Estimated depth to ground water S 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 h*within 150 feet of SAS) ' ti Checked with local Board of Health-explain: fie t ®'2 Cbecked with local excavators,installers-(attach documentation) - Accessed USGS database-explain: You must describe bow you established the hlgp ground water elevation: � r 2 i o°Z i,/Si t-' ?ivN, dill j t I { { 1 {l { TOWN OF BARNSTABLE LOCATION ('�s ��waa� �� SEWAGE # VTUAGE, yl -r—� ASSESSOR'S MAP & LOT a979 AV-1 INSTALLER'S NAME 8c PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS 3 BUILDER OR OWNER 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 leaching facility) Feet Furnished by .f TOWN OF BARNSTABLE 1�T E LOCATibW / / ? �iQlj P� SEWAGE # VILLAGE / ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) e2 1eG ^S ,T(4�— (size) ,/ Dae) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMkT ISSUED: DATE COM IANSUED: " VARIANCE GRANT • Yes o �— rJpS G 1 (,_\ �. 1 V � f .n �"�� ,� ,� _ � � o � , � �' `� d� � � • a . �� Q ��� � �� �� �'� �:'. , , _ `� ,' TOWN OF BARNSTABLE LOCATION' /� Ll/'��icJDD� SEWAGE # VILL--AGE /V ASSESSOR'S MAP LOT jg-o'ffK INSTALLER'S NAME ,� PHONE NO.,%Pr�/�j SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �i 7�S (size) jd D0 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER M OR OWNER 1,71 � DATE PERMIT ISSUED: �"� DATE COMPLIANCE ISSUED• VARIANCE GRANTED: Yes No J �� _ ,� �� �" � /�� �. `w �yt _, \ � 10� � �� � � � �� � � ����` , .r/t ` .�f'K i`� d _ 1 No.... P APPROVED THE COMMONWEALTH OF MASSACHUSETTS j5i9nLedZA � BOARD OF HEALTH 3 /57 TOWN OF BARNSTABLE f irafth for Dili ana Work " Cnonfitr Pion a � t� At.f ttttt Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 145 Buck. ood Drive Hv.anni-s........................ Location-Address or Lot No. James Satko ......................_......................................................................... -•----------•-----•••--•-•--•-------...........--•-••--•-----•---•.........•--..._....•--......... Owner Address W J.P .Macomber Jr. Installer Address PQ UType of Building Size Lot............................Sq. feet �.. Dwelling-X No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons---------------------------- Showers — Cafeteria p' Other fixtures ............................... .. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity...........gallons Length_____________ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter--._.-----....___._- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ---•---•---------------------•---•-••••-•-•-•-•......---•••-••••-•.....•----••••-•••-•-----•-------......................................................... 0 Description of Soil........................................................................................................................................................................ x Sand & Gravel V ....-••----•.............•••----•••---••--••••--••--••••-••••-••••••••..__.....••--•••-•--•-•----............---•---••••-••••---•-----------•--- W -----•-••••-------•......................................•---------•--------••--------------••.........-----•------------••--•-•------•-••---••-•-•••••-•-••••---•-••••••................--••----•-•.... UNature of Repairs or Alterations—Answer when applicable__.--_-- ci i-- 1-1000 o a..l o n leach o i t to an-- i.s.tin � n!i_..&... it-•--------------------•---------------------------------------------------------••--------------------------.......•...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has ben/sued by the b and f health. Signed � .......- ........... ,...........................1 .¢ ...... Application Approved By ................ J. ..... ------ �,�.�. - ---............. .... ... Application Disapproved for the following reasons: ... ... .. .........................I.......... --......................... ................................. .... .............................................. ...................................... ... ... ............... .. Permit No. 7Y.. a;. .Y..---?-------------------- Issued ......................................................... Date...... Dace Ficic.A....30 00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 11_35 7 TOWN OF BARNSTABLE Appliration for Ui i niul Work Cna�tt�#r r#tnn prtttt# Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: I` 145 Buckwood Drive H annis - ......•--••-------•-----•-•-•----------•------•- Y... .............................. --------------------------••-•-•-----•••-------------•••--•--•----•----•..............._......••-- Location-Address or Lot No. James Satko _... ------------------------------•----•-••-•-•---•• ................................................-•••••------------............................... Owner Address W J.P.Macomber Jr. ,-I -----------------------------•--••--•----...--------------------------------------------------•--- ---------------------•---•-----•-•--f-........................................................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling }�- No. of Bedrooms---------------________________________-.-_Expansion Attic (, ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QI Other fixtures -------------------------------• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity........___gallons Length---------------- Width---------------- Diameter---------------- Depth................ t x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......... .......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................. --------------•---•--------•---•---•----------•-----•- Date........................................ Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -----------------------------------•----•------------------..._...--------------•---........................._..:.:... 0 , Description of Soil-•------------•----------------------------••-•----......_.........- Sand & Gravel -------------------------------------------------------------------------•--------•--•---.._....--- V ..-•-•-•-----•...........-•----••----....-•--------•---------------•-----••---••--....---••---•-------••-----••---------•-•----------........._...---------••-••----.............-•••---------••-••---•- W U Nature of Repairs or Alterations—Answer when applicable........Ad d i ng 1-1000 gal 1 on 1 e..Ch p .. to an...P—mi.a t 1.ng..#s"�nK..-&--- it,-.-•------•--•-•----•--•---------•---•-•----•---•--------•-------•-•-•---...---••........................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board f health. 5/11/94 Signed ..... . � - - ------ !1 ................. ...' ................. Dace ��yAP - . � - Plication Approved BY ..... ... .. --._ Dace f Application Disapproved for the following reasons: ............................................................. .._......... ......,....... ................................. Permit No. ---------7 -.............. ...1 y � L/ - ... Issued .............. .......................................e...... Dace i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �1ertifirate of Q-Tont3ltianre 3"HS IISa��a�oE7FJYr That the Individual Sewage Disposal System constructed ( ) or Repaired (KXX ) by ---1—ak, 145 Buckwood Drive Hyannis ..................._...__.. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated . .. ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-...........,. ...... 1...-,. -.._. .. /----------- lnspec or-----.....f Y:.. ..-..: 'f4 �. ,. -)—... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ��- a�� 7 FEE.. ...30:O0 No........ ... '4 Mappsal Works Tomitrudilan prrmi# J.P.Macomber Jr. Permission is hereby granted----------------------------------•-----------' to Construct ( ) or Repair X) an Individual Sewage Disposal System 145 Buckwood---- rive Hyanni_s... -•-------------•----------...--- --------------------.._........... at No. ... --•----• Street e� as shown on the application for Disposal Works Construction Permit No.l�y:_�_c��Dated.._.....���_.`�_3.'..c�.��... ,r: . •------••----••---------•-•----•••-•---•-------- Board of Health DATE _5.. ......----•-•. FORM 36508 HOBBS&WARREN,INC..PUBLISHERS u } No..•-•� -1,...-• Fas..d:�Id THE COMMONWEALTH OF MASSACHUSETTS „L BOARD OF HEALTH \h • ................. 2� t� ' Appliration for Bgsposa1 Wanks Toustrurtgon rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: y y �11• ..... --•-------------------•---.....---.....-- •.........----•••.----•-.....-----•.........-----..---•------.......tUA V.. Locatio Addre � or Lot No. ............1.�GAIXO.V .......... ,� ..................... t Owner Address W Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........j............. .Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria Q' Other fi u es --•-•-•--------•------------- ........................................... .. W Design Flow.............. ............................gallons per person per day. Total.daily flow........ ..........................gallons. R$ Septic Tank—Liquid capacity/2?�24... a_11 us Length::Width________________ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No..._f Q�_�____-. Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date-----------------------------------..... a Test Pit 1\o. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------- T Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water______________________-. R+ --------------------------------------•-•---------•-----.......---------------------------------............................................................. ODescription of Soil........................................................................................................................................................................ .-••-----•-•-•---••-•----•--- i° ' 1: dPU --'-------------------------------------------------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable..-__.........................................................................................:. --------------------------------------------------•-------------------------------------------••-•-----------------------------------------------------------------------------------------............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beVied by the board of health. '�Signed.- . �-l-�c• ...��, c9�,.-_. ............................. Application Approved BY-----11he --1.�1. /r,o :._e. .:-- - ---------------------------------------------------- .................Date.............. Date Application Disapproved forollowing reas 's-----------------------------------•-------------•---••----....••-------------------••-----•.....------•-------•- ..------•---••-------------------------------------------------------------------------------------------I----------•---....--------------•-•-----------...----•-------------•--••...-------------------- Date Permit No......................................................... Issued..... _: Date No.......�L"l........ F i .. .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF....... Appliraflun for lgigpmial gurks Tomitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: <0$,, 5,�y / p _��li,lt`,A,/W.1y, ............. A............!!�.9;........................................................ ................................................................... ...................... try Location,Address or Lot No. ........... . . .................. .................. ............. ... . ...... ...... Owner Address .........................................................................................,........ .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........1j..............................Expansion Attic Garbage Grinder ( ) P-t Other—Type of Building -------------------________ No. of persons....__:____._._..____._._.__ Showers Cafeteria ( ) PHOther fixtures .................. ..................................I......................................------------............................................. Design Flow............... .......fir......................gallons per person per day. Total daily flow__._.._:... -------------------------gallons. WSeptic Tank—Liquid capacitye!__� 7...g,11 s Length._,J�*' Width________________ Diameter____.____._._.__ Depth................ Disposal Trench—No_ ____________________ Width___._..___..__.____. Totab.Length-------------------- Total leaching area....7...............sq. f t. Seepage Pit No-_.;.:642_6i------ Diameter.................... Depth below inlet_...__._.____...__._ Total leaching area..................sq. ft. Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-___---__._________ Depth to ground water_--.---.----_--__--.---. fX Test Pit No. 2...............minutes per inch Depth of Test Pit..__.._.._.____..___ Depth to ground water__-___________________-- ' R+' -----------*..................................... ......*---------------------------- 0 Description of Soil.......................................................................................................................................................................... x ...................... A, ........................ ............... iC r i t g ................................................................................................. U ---------------------------------------------------------------------- ----------------------------------------------------- ........................................................................... Nature of Repairs or Alterations—Answer when applicable.._------------------------ .................................................................. ...........I................................................................................................................. -------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been.issued by the board of health. ................................. Date ApplicationApproved By...... -'-4 .................................................... ........................................ Date Application Disapproved forqhe following rea Ows:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH OF......... /a, ......................................:... ............................................................................ 9. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired a by-------------_-------- •;....................................................................................................................................................................... at............._Z.,V. ........................................................................................................... ................................................................. has been installed in accordance with the provisions of Article XI of The State Sanitary. Code as descr ed in the application for Disposal Works Construction Permit No........ ------------------- dated.---__6 ._'-_6............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---- Inspecton'.. -----7 .......................................... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .OF.................. ............... ................................................................................ No........... ........ FEE........................ Permission is hereby granted_____._ ;..;...... ........ ... .......P.,1z.1,-4 ------------------- ............. ......................... to Construct or Repair an Individual Sewage Disposal,- System at ................................................................... .......... ......at No............ Ir......... ...... Street as shown on the application for Disposal Wor'Ks Construction PIV, it No. ...... Date4, 4 —--------------7....... :.�------------ -------------------------------------------------- ........ 'Luard of Health DATE. ......................... ......... FORM 1255 HOB13S & WARREN, !NC., PUBLISHERS *NOTE: ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. 10' min. from SECTION A -A -AIN Existing Foundation house to septic tank PROFILE VIER OF ADDITION TO LEACHING SYSTEM S. tank covers must be w-BOX*• o}_GRADE be rade1/2* a # ¢# w In a In. of finished grade RADE G over Septic Tank - 94.00 0rode over 0-Bon- 98.00 over SAS - 98.00 3" of 1/8• - 1/2• Washed Peaston z ► ' �, iz's s -- 3 HOLE H-10 3/4' to 1 1/2 Washed C eh•d Stone DIST. Box S - 0.02 4•PVC(CAPPED) INSPECTION PORT TO K3 10 EXIST. s-aw ar Greater 3' Maximum Cow Top OF Sywtem- Elev. -95.23 INSTALLED AND TO BE VATINN s•OF GRADE s ; t #z tits �.' i # iz f s Z EXIST. PIPE 01,000 GAL. S. 0.01• C t 1is I, r FROI EXIST. FOUNDATIaI `$� SEPTIC TANK g Per 0" EH*otive Depth €t f#; N obi + s CONCRETE FULL F°t1NDA II H-10 N 0.83 5 Units ! 6.23' 30' I Ii 1 #` I I !Pill #°' nri c, 3' (10 Inches) 3 l; 31'sF, 3 £ t o+ g n pleb, 4!f T�fiirr !w t 3ta • t # fy SYSTEM PROFILE , ° In of 3/4--1 /2 $ ; 9 w 31.25pq Not to Scale °°""p°�'° '`°"' _ � 11 °' 3 Effective 7,2 GENERAL NOTES 3.5' 3.5' p Length 5 3, : SOIL ABSORPTION SYSTEM (SAS) 1. Contractor is responsible for Digsafe notification, Verification of Utilities B In.of 3/4•-1 1/2• 10 'a and protection of all underground utilities and pipes. compacted *tons Effecaw vktth I.J INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN 2. The septic tank and distri u$ion box shall be set NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 8" BELOW GRADE J CS (OR EQUIVALENT) Not to Scale level on 6 of 3/4 -1 1p2 stone. 3. Backfill should be clean sand or gravel with no NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" stones over 3" in size. PERCOLATION TEST Bottom of Tat Hole 1 EI•v.- e7.00 4. This system is subject to inspection during installation b Carmen E. Shay - Environmental Services, Inc. Groundwater observed - NONE OBSERVED 5. The contractor shall install this system in accordance Date of Percolation Test: MARCH 19, 2008 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By.DONALD DESMARAIS (BARNSTABLE BOH) 6. If, during installation the contractor encounters any EXCAVATOR: RODNEY FISHER M soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI tD 30" DISTRIBUTION �K ,r from those shown on the soil log or in our design SET LErcL INAT LEAST 2 FT. COVER installation must halt & immediate notification be ��_ Kitchen � Bedroom Test Hole Test Hole 3- W 01.17M Dining S made to Carmen E. Shay - Environmental Services, Inc. No. 1 No. 2 KNOCKOUTS 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV. DEPTH SOILS ELEV. - °'s• OUTLET 1r INLET septic system unless noted as H-20 septic components. 0 98.00 0 98.00 s• e• 8. Install Tuf-Tito gas baffles or equals on all outlet tee ends. Sandy Sandy ''" ' "' Living Room Bedroom 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Loam Loam /aIY 4" - SCH. 40 T• t,Tt1• 10. All solid piping, tees & fittings shall be 4" diameter 10 YR 3/2 10 YR s/2 PLAN SECTION CROSS-SECTION Schedule 40 NSF PVC pipes with water tight joints. o"-e• Loamy y AP 97.5 o'-e' A, 7.50 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sand Sand 3 HOLE H-10 DISTRIBUTION BOX 2 BR HOUSE FLOOR SCHEMATIC Properties Within 150 Feet. 10 YR 5/6 10 YR 3/9 (Description Provided By Owner) a"-3o" Bw 95.50 eve-30" 8, 95.50 THE PROPERTY LINES ARE APPROXIMATE AND Mod. Mod. CB D.H. COMPILED FROM THE SURVEY. PLAN BY MERCER ENGINEERING CORP. Sand Sand FND ENTITLED LCC PLAN #35404-A (SHEET 1) 2.3 Y 7/4 2.5 Y 7/4 DATED FEBRUARY 26, 1968 on AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN •- 132 C' 87'� '- 132 C' 87'� 75.00 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN THE SEPTIC SYSTEM INSTALLATION. TEST HOLE #2 EXISTING LEACH PITS TO BE PUMPED OUT AND FILLED IN PLACE g 0 ELEV.- 98.00 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE TEST HOLE #1 FROM THE EXISTING LEACH PITS TO BE DISPOSED ELEV.- 98.00 OF AS PER BOARD OF HEALTH SPECIFICATIONS. Perc #1 22.75 5' THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 30" to 48" ,.•' , ,•, •► ��,,•, Perc Rate- 2 MPI 1 ;� . • �:t• • �y D-Box ASSESSORS MAP 272, PARCEL 086 Groundwater Not Observed cQ .w y, . !v; •a �'h"w�,l,; ' No Observed ESHWT aLEGEND ADJUSTED H2O Elev. - None 7.25' DENOTES PROPOSED 2-18' DIAM. ACCESS MANHOLES ____ 104X1 SPOT GRADE Failed Fa led r Leach Pit ti Y, PROJECT BENCH MARK _ Leach Pit s ' N DENOTES EXISTING i �'- -'�' TOP OF FOUNDATION x 104.46 b - SPOT GRADE ELEV. - 100.00 (Assumed) 04 3 ?7(u Y EXIST. f I ,l . PL PROPERTY LINE INLET ••. V - \ .. OUT � 1000 al. � S r � I O Septic 91ank C.,AV` ram, J 96 PROPOSED CONTOUR ` THE ACCESS COVERS FOR THE SEPTIC TANK. .� _h�� DISTRIBUTION Box AND LEACHING COMPONENT --_--- 0'� �� SYJ CaIrM - - - - - -97 EXISTING CONTOUR I�rr;• ,.., SET DEEPER THAN a INCHES BELOW Fr03FED r , •STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. RAISED TO MRTHIN e OF GRADE SHALL K `0 Col eye fu,e, 1 1 EXISTIN' l (� , ���ld 1 DEEP TEST HOLE & PLAN VIE W INSTALL TUF-nTE GAS BAFFLES OR EQUALS 1 I � N 1 1 R BEDI100A.r � �Qn 3 e!c PERCOLATION TEST LOCATION 3-20 RQ"0`C01ER' I I' HOUSE ' r o� e--+ 6 FOOT STOCKADE FENCE mine ,rn m�i.to outlet •,ry'� ( �" INLET I Y / 10'mR i�{' U�Tevwl-,s' 2 OUTLET s• _r a I 99-- --;----- --I►I-- I------ - (n�(X `s°1� PLOT P LAN 4'-0* min } _ / taw �°"'° dp"' I -- ' �`" "r1 e l OF PROPOSED SEPTIC SYSTEM UPGRADE •, ,gyp a. \ _ E G DE "T #2c t V 3 BRd PREPARED FOR 98 ------- --I tr-o' T I 11,0,25 square Feet +/- -__ 97 ��-• CROSS SECTION END-SECTION I MATH EW H U.R D 97-- --{-------- -- ------------------ --96 AT TYPICAL 1000 GALLON SEPTIC TANK 96-- --r------=;�- - # 145 BUCKWOOD DRIVE NOT TO SCALE I I i `� 75.00 -� H YA N N I S, MA _ '9s - F PREPARED BY: Number of Bedrooms: 2 e room 'EXISTING �� ------------------------------------- ,,� ' Leaching Gripper:yNo qGal./Day ( ) ___ C�4RM�'N E. SHAY Leachin Capacity Required: 330 MIN. PER TITLE V _ t Septic Tank - 2 x 330 Gal./Day - 660 USE EXIST. 1,000 GAL. Septic Tank. B E. U CK W O O D DRI V E ; T NVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min nch C Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. - 273../(gallons \ 1�"� 85 ASHUMET ROAD Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. - 58 gallons - (40 FOOT RIGHT OF WAY) 0 20 40 50 �,sT�R�° 'MASHPEE, MA 02649 Providing: - 331.80 gallons - __-__--__ , 4N/rtiR\aN TEL FAX 508-539-7966 Use. (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, `�- SCALE: 1„=20' DRAWN BY: CES DATE: MARCH 19 2008 TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3' OF WASHED STONE SCALE: 1~=20� ON THE ENDS. No STONE UNDER. PROJECT#SD1080 FILENAME: SD1080PP.DWG SHEET 1 OF 1