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Home My WebLink About0176 BUCKWOOD DRIVE - Health 176 Buckwood Drive Hyannis P -- A = 271 109 I 9 a d 4 i Q\ COMP4ONWEAL7H OF MASSACHUSErrrS ExECUTm OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTN9WT OF ENMONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION j Property Address: 176 Buckwood Drive Hyannis Owner's Name: B i 1 1 mnw i 1 1 i;4znc /' ®� Owner's Address: s 7 ti .->u,, %11QQC1 D -;ye ! �I / Date of Inspection: # t'17 Name of Inspector.(please print)_ Sean Jones Company Name: William E. Robinson septic aerv.L%;e Mailing Address: P ® Box 1089 e Centerville, 14A Telephone riumber: t.fl81 775—B776 CERTIFICATION STATEMENT t certify that 1 have personally inspected the sewage disposal system at this address and that the infoi nation r eponcd � below is true,accurate and complete as of the time of the hapection.The inspection was performed- a on my, �= training and experience in the proper fta melon and maintenance of on site sewage disposal systems. m a DEP= -� approved system inspector pursuant to lose 15-W of Twe S 010 CuR IS 00). She system: r� Passes cry Conditiona!!y Passes Needs Further E a cation by the Local Approving Authority Fails inspector's Signature: Date: Titc system inspector shall submit a copy ofdds hmpecOm seport to the Approving Authority(Board of Heauhvr DEP)within 30 days of completing this Vie.If the sysum is a daared system or has a design flow of 10,000 gpd or greater.the inspector and the sysmem over shalt submit the tepott to the appropriate regional office of the DEP.The original should be sent to the gstcm owmr and copies seed to the buyer,if applicable,and the approving authority. , Notes and Comments •••*This report only describes conditions at the tip of hispection and tirades the conditions of use at that time.This inspection does not address hoar the system wHI pedbrm in the future under the same or different conditions of use. Title 5 inspection Form 6115/2000 page 1 Page 2 of I! t r OFFICIAL INSPECTION FORM—NOT FOR YOLtINTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION(continued) Property Address- 176 Buckwood Drive Hyannis Owner. Bill—McWilliams , Date of Inspection: r 7 Inspection Summary; Check A,B,C,D or E l ALWAYS compleft alI of Section D A. Systeld Passes: I have not found any Wor mation vduch indices that any of the faftn coterie described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any fat'lu re aiteda rmi evaluated are indicated below: Comments_ i B. System Conditionally Pauses: ` r One or more system components as described in the"Couditiortai Pass"section need to be replaced or repaired.The system,upon completion of the rephcement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the folhtwbg statanents.If'tot determined"please explain. The septic lank is metal and over 20 years old*or the septic tw&(wtrcther metal or noij is structurally unsound„exhibits substantial infiltration or extilbatim or tank failure is -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 snit or high static water lived in Me distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven&sId-butiort box.System will pass inspection if(with approval of Board of Healthy. broken pipe(s)are replaced oboucfien is removed di$WbWon box is leveled or tt:placed ND explain: The system required pumping morg tban 4 tomes at year dire to bmkcs or obstrumcd pipets).The system will pass inspection if(with approval of the Board of Health): brokers pipe(s)are replaced obi is rtmvcd ND explain: I� - �Page 3mfil OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 176 Buckwood Drive Hyannis Owner. Bill McWilliams_ Date of Inspection: a �� C Further Evaluation is Required by the Board of Health:,/\j Conditions-exist which require huther 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 1S.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 SO feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic-tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froth a private water supply well" Method used to determine distance ''This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION(continued) Property Address: 176 Buckwood Drive Hyannis Owner: Bill McWilliams Date of Inspection: i`l ,7 D. System Failure Criteria applicable to all systems: You must indicate`y+es"or"no"to each of the following for ail inspections: Yes NO ✓J/Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool J Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool 2 Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or /cesspool ✓/Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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 i00.1eet of a surface water supply or tributary to a surface water supply. /Any portion of a cesspool or privy is within a Zone I 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 K-atcr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria A are triggered.A copy of the analysis must be attached to this form.} /v- (Yes/No)The system fails.I have determined"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 now of 10,000 gpd to 15,000 gpd- You must indicate either"ycs"or"no"to each of the following: (Tlte following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(lntuim Wellhead Protection Area—I WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E lbe system is considered a significant threat,or answered "yes" in Section D above the large system has failed..owner or operator of arty large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 0€11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 176 Buckwood Drive yannis Owner: Bill McWilliams Date of Inspection:_ �2f s LC/�0-7 Check if the following have been done_You most indicate`des"or'W as to each of the following: Yes No/ !//Pumping information was provided by the owner.occupant,or Bowd of Health Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in'the previous two week period? �/✓ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of I'rgnid,depth of sludge and depth of scum? JWas the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure aiteria related to Part C is at issue approximation of distance is unacceptable)13 10 CMR 15.302(3)(b)j 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address• 176 Buckwood Drive Hyannis Owner: Bill McWilliams Date of Inspection: 1 ` o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x tl of bedrooms): Number of current residents: v Does residence have a garbage grinder(yes or na)..� - is laundry on a separate sewage system(yes or no):L- [if yes separate inspection rcquiredj Laundry system inspected(yes or no):2 A Seasonal use:(yes or no):Aw 7 f 05 to 7 j 0 6 —4 3 5 0 0 Water meter readings,if available(last 2 years usage(gpd)): 71015 o —12 r 0 0 0 Sump pump(yes or no): ' , Last date of occupancy: — COMMERCIAL/INDUSTRIAL j� Type of establishment: f Design flow(based on 310 CMR 15.203). Rpd Basis of design flow(seats/persons/sq etc.). Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Pate 7 of I I OFFICIAL INSPEMON F011lli—NOT FOR VOLUNTARY ASSESSAIL•'NTS SUBSURFACE SEWAGE DISPOSAL SYSTEAJ INSPECTION FORAM PART C SYSTEM INFORMATION(continued) Property Address: 176 Buckwood Drive Hyannis ot•ncr: Bill McWilliams Dale of Inspection: e. ,,-7 BUILDING SLWLII(lucut on site plan) utpUt below grade: � Maletials of construction:_cast itott h/4u PVC_uUter(explain). Distance ffotn private watef supply s.clt or suction lust:_ Cut►ntctrts(on condition of joints.vcnttng,cvidctcc of icakagc,etc.): t3 min- /Va ( er„t£c L- 5LPTIC TANK:Zvocatt oil silt plait) Dcptll below grade: 7�f � Material of eonstructiott: ✓concrete total fiberglass awl?eUhy{ene _utl►ct(cxplain) — —" It tank is metal list age:_ _ is age cunfitnted by a Ccftifrcat ccnificatc) - e of Compliance(ycs or no)__(attach a Cully of I Dimensions: /� C, Uans Sludge depth: l2, Distancc front lull of sludge to but10111 of uutict ice or baffle: b7• , Scut thickness: 02" Distance from tup of scut"io lull of uutict tee or banic: to Distance from button,or scunh to botrorn oroutict tec of ba(tic: n" How wcrc dimensions determined: A;tgd Cam-- � Continents(on lumping rc Evil mcnJations.inict and outict tcc or Gattic cortJitir rt,structuhat integrity,litluiJ IcrCk as related to outicl invert,cvidence of leakage,cte. : �,ct 5�r- •�.�� ..`�...,•�� t.�c �� •N GREASE TRAP: catc of site plan) Dcptlt below grade:_ Malcrial of construcliun:_concrete metal fibctglass__lulycolylcnc-_oUtct Dimensions: Scum Utickrtcss: Distance from top of stun►to top of outlet Ice of bank:Distancc front button,of scum 10 boltum of outlet tee ar ba_flfc: Dale of last pumping: Cununcnts(on pumping tccanuttcndaliuns,ir►Icl and uutict tcc of baffle cundrttvat,struclutat wtcgr ity,liquid Icy cis as related to oullct inccil,evidence of lcaka&c,cic-): 7 )'age S of 11 ' OFFICIAL 1NSPLCTION FORM-NOT 1.011 VOLUNTARY ASSL,% Rhj •:N"1'S SUUSUIWACE SENVAG1: DISPOSAL SYSTE61 1NS1 EXTION FORM PART C SYS'I'L'�I INF ORMAT10N(cuntingcd) Property Address: 176 Buckwood Drive Hyannis Owner: Rill & 1 ' ams Dtut of lospcctlon: I TIGHT or HOLDING TANK: `v! (tank must be puraped at tirne of inspection)(locatc on site plan) Dcpil►below blade: Material of construction:,_ctntcrcte_rttctal_fiberglass_�mlyeihylcne otltct(exptain). Dinscnsions: Capacity: aligns Ucsign Flow. gatlunsiday Alarm present(yes ur no): Alum level: Alann in wwking utdcr()-cs ur no). Dale of last pumping: Cununcnts(condition of alatm and nuat switches.ctc_)= DISTRIBUTION BOX:zorplEscol must be ul:cncd)(locatr on site plats) Dcpth of liquid level above uutkt inert_ �,• Conuneuts(note if box is level and distributiuu ig outlets equal,any cvide"ce of solids carr)•ovcr.any evidcuce of Icaka c into or d out of box.etc.): ox ��-r�� r ram, �oa� C��tcl��i� s�ir�Lt �-�,y��• r_ c�s<r cAd�ro PUMP CJIAMULH:fJ�(ucate on site plan) Pumps in working order(yes or nu):_ Alarms in working order(yes or no).` Cununcnts(note condition of pumyr cttamrbcr.Sundiliun of pumps and appuricnatt(cs,etc.): I Page 9ofIF OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 Buckwood Drive Hyannis Owner: Bill McWilli s Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): {locate on site plan,excavation not required) If SAS not located explain-why: Type aching pits,number._ leaching chambers,number: 2 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 pondittg,damp soil,condition of vegetation, etc.): 41X-sC oj_� ,�^i•Y.,.�L.� ,.,, (-e/' n <Sf�t:� [•-ct wa3 V in t. ��J».-•.- �orar' r ...�, CESSPOOLS: J Acesspoot must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level o€ponding,condition of vegetation,etc.): N1PT PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of pond':ng,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 Buckwood Drive Hyannis Owner: Bill McWilliams f Date of Inspection:i 7 %K -o7 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. ------------- �R� O,F :ilovSc vX L Tq�� A_ f . 3c�' ate' a kE" A -Y = `fs` 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 176 Buckwood Drive Hyannis owner. Bill McWilliams Date of Inspection- I.t Ja? SITE EXAM Slope �--I—+ Surface water nro M c Check cellar D,Y Shallow wells n� t Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: -V Obtained from system design plans on record-if checked,date of design plan reviewed: 3 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: D2 S'S P�are ho.�G� rllD ;..A tca— e >3.7' • .w dG SAS t S vPt n K 11 TOWN OF BARNSTABLE LOCATION SEWAGE # . -;c o "i 4 L VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Lod ►-��a�� S�A i SDI-??S-�f 7 7 SEPTIC TANK CAPACITY 306 . LEACHING FACILITY: (type) 3 NO. OF BEDROOMS-1- BUILDER OR OWNER PERMTTDATE: 7 e�a ? COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (Many wells exist Feet on site or within 200 feet of leaching facility) - Edge of Wetland and Leaching Facility (If any,wetlands exist Feet within 300 feet of leaching facility) Furnished by 0 i � 5a s No. 3—30 Fee u THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mi.5po.5al *p5tem Conelruction 3permit Application for a Permit to Construct( )Repair(W)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addre s or Lot No. Onprl;s Name,Address and Tel.No. Assessor's Map/Parcel� \..._S Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No. 4, r • f 0*r 8�t c5 p c. . �� '�r91IC;® ,�/L(/ i�'oh r L --t C,i,��f� pAa-/0a-, Cmvt/za//k, c�cc*,IewsS jr7 121wit(i Type of Building: Dwelling No.of Bedrooms _3 Lot Size sq.ft. Garbage Grinder(f�i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answ r when applicable) S ��ew1 7U g✓ , v is/�C� n� c A ? 6_1�_ 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 E ironmental de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this f�Health. Signed Date v Application Approved by Date 7 U-U 3 Application Disapprove for the following reasons Permit No. 'Zoo 3 -?` Y' Date Issued -7- Z?-°3 J -w .r-w'rti V✓ N "�....-..�..�-+-- ......--..-:. -_, .mil r - - 1. .. «,. _ _ _ No. 31,7 3 U / ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes /k - +� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Appfda on for Ziopooal *potem Construction Permit Application for a Permit to Construct Repair(�Upgrade( )Abandon( ) ❑Complete System ❑Individual Com nents �P� ( . ) P )UPg P Y Location Add s or Lot No. Ow�ne ' Name,Address and Tel:No. / (o i6 u��d l rh nLY 6ZZA,q nay+ Assessor's Map/Pazcela Installer's N e, dress,and Tel.No Designer's Name,Address and Tel.No. o � � .e o fi! �41�C0 �nU ��'vY� rrt erlT 1 su/f�� (Q.ova-/O 8-9 Ca nX�141� ./rk_ C.t Cirvrvs S .4 n &n/1 Type of Building: t r,1 7 Dwelling No.of Bedrooms J r Lot Size sq.ft. Garbage Grinder(/ c Other Type of Building ` No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �t �+ Nature of Repairs or Alterations(Answer whe �/cS/.Q applicable) � 17-e �� Ol•� �� :yam sILP41 7~U / S G 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 E ironmental de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this ar `Health. J 3 Signed Date Application Approved by s Date Application Disapprove for the following reasons Permit No. 2 Up 3 - `/`f' Date Issued 'f- 2-F-a 3 yeah THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS €€ (Certificate of Compliance THIS IS TO CERTIFY, that the On- ite Sewage Disposal Sys etn Con cted( )lfepaired(Upgraded( ) Abandoned( )b k/1'1'1 ,F- Rc2b a fe;W -4-- at �i� LC C.IC 10010 47/1" S/,/ W t1/S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.X 3 3 q dated 7- 2 8-U 3 Installer I Designer The issuance of t�i pe it shall not be construed as a guarantee that the systemftTi de Date Ib Inspector No. Z-y 0 3— 3 y 4 Fee �. CO �9nG� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Zigooar *pgtem Conotruction Permit Permission is hereby granted to Construct( )Repair(,,Upgrade( )Abandon( ) System located at 14)0,17.FJ 0✓' 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 permit /�^ Date:_ 2 63 Approved by TROY WILLIAMS &A SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road ° South Dennis,MA 02660 Cz tth of MCWoC Usetts o@ ke 6 -, Executive Office of ErnUonnvi tal Math i`�"'� Department of '� Py Environmental Protection V=am F.Wald fawamor D"B.Struhs w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 17 C7 U c..k,-j o a d 0, J- ,V K N N. s Address of Owner Date of Inspection: y 6 v vh y o r Name of I `3/�9 / (If different) nspector: �- J j, 1 Company Name,Address a�sd Telephone Number: R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection..The inspection was performed based on my training and experience in the proper function and maintenance of ors-site sewage disposal systems. The system: -ZPasses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000.gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: -- i have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. el SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced a repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no. or not determined (Y, N, or ND) Describe basis of determination in all instances. If'not determined', explain why not) The septic tank is metal, cracked structurally unsound, shaws substantial infiltration or exfiltruioo, or tank failure is imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C k w0 od Owner: Date of Inspection: f2/ `` h 3 /ly /� 6 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:///,9 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system nas a septic tank ano soli aosorpuon system and is within 100 feel to a surface water supply or tributary lc a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 'I SYSTEM FAILS: n//n I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination Is identified below The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool -wised 8/IS/9S1 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / 6 So -k w o od Owner. pp Date of Inspection: DJ SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 11 LARGE SYSTEM (AILS: /V 14 The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) 1 he owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program equirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. r w ised 6/15/95) 3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEMON FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: 311g1y6 Check'if the following have been done: Pumping information-was requested of the owner, occupant, and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 1�1g As built plans have been obtained and examined. Note if they are not available with WA. _ZThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow V The site was inspected for signs of breakout. ZAII system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility ownP (aid occr)pants. if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. revised 8/l5/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property rAddress: � 7� o c.k l;J o o d` Owner. y K Date of Inspection: / FLOW CONDITIONS RESIDENTIAL: Design flow:as 6 gallons Number of bedrooms: .2 Number of current residents: D Garbage grinder(yes or no):,j Laundry connected to system (yes or no): YE 5 . Seasonal use (yes or no):-4!Z S Water meter readings, if available: . 95- = /7, 000 G r / y — 3_ oT d V _ast date of occupancy: s LJ' W«tf-eh't S� . COMMERCIAL/INDUSTRIAL: type of establishment: Design flow: ttallons/day :grease trap present: (yes or no)_ ndustrial Waste Holding Tank present: (yes or no)_ ,Jon-sanitary waste discharged to the Title 5 system: (yes or no)_ eater meter readings, if available: ast date of occupancy: OTHER: (Describe) ast date of occupancy: GENERAL INFORMATION "UMPING RECORDS and source of information: /U� a'Lwrg2crJ y 7/ld / urhs � /t System pu ped as pan of inspection: (yes or no),/U If yes, volume pumped gallons Reason for pumping: t YPE O SYSTEM Septic tank/d4u4au6e443,9Jsoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: ✓ C^ a� ewage odors detected when arriving at the site (yes or no) //U :evised 6/1si9sl 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17 6 , 8,)`k w o Sul Owner. R Date of Inspection: Y�`h 3 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: ,concrete _metal _FRP—other(explain) Dimensions:_ k G /Dt>a 414 Sludge depth: '� el Distance from top of sludge to bottom of outlet tee or baffle: L a Scum thickness:�� Distance from top of scum to top of outlet tee or baffle: N Distance from bottom of scum to bottom of outlet tee or baffle: NO 5 . Comments: irecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural me rity, evidence of leakage, etc.) C-11 �. � �`' ,, ,�, ; ,� I c--I- . �,R �„� X e3�t ,4 T GREASE TRAP:-L//4 locate on site plan) Depth below grade: material of construction: _concrete _metal _FRP —other(explain) Dimensions: ,cum thickness: Distance from top of scum to top of outlet tee or baffle: "111_tance from bottom ni -ti— i- hotiom of ou!ie! tee or bante omments: recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ntegrity, evidence of leakage. et(..) :wised 8/15/951 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L SYSTEM INFORMATION (continued, Property Address: ' 76 3 i c-n- w o a d Owner. Ry " Date of Inspection: � TIGHT OR HOLDING TANK. (locate on site plan) Depth below grade: material of construction: _concrete_metal_FRP other(explain) Dimensions: Capacity: pllons Design flow: eallons/day alarm level: Comments: :condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:n/Ay locate on site plan) Depth of liquid level above outlet invert: omments: note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: ni�y locate on site plan) ;,Limps in working order:(yes or no) omments: note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 6 6o,-k.-woo1 Owner. n Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods) if not determined to be present, explain: Type: leaching pits, number:Qy c �)C G Z cu�, (�� %�S)ZI leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of pon ing, condition of vegetation,etc.) a la d 1) ( c✓ S ` J CESSPOOLS: J� 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: ,.taterials of construction: ndication of groundwater: inflow (cesspool must be pumped as part of inspection) omments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: locate on site plan) %Aaterials of construction: Dimensions: )epth of solids: omments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ,e�ised eiisivs� g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: a✓7 6 /✓R U L k w o o a d9r, Owner: Q Date of Inspection; r l y 3A �► SKETCH OF SEWAGE DISPOSAL SYSTEM: Indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' BQ C-k_ . 30 ' . 3� as ' -fovby� i• . 36 b 6 'X-6 ILCCC- � w� I S 40 c. . >EPTH TO GROUNDWATER >epth to groundwater: — feet — adjusted high groundwater level ,�ethod of determination or approximation: �(J a J C Q1� L4 1...N 1 �. !� rV / 1 Y 1 J W 4 �.✓ t� a a3 <<vi.ed 6/15/95) g TOWN OF BARNSTABLE LOCATION 1�/� A 11C IC CPC�0 D ( Rij& SEWAGE # VILLAGE (4yA ywt.S ASSESSOR'S MAP & LOT i INSTALLER'S NAME&PHONE NO. rb6 i FJS6,,}� l k S6'2-?7 S- 7 i l� SEPTIC TANK CAPACITY --r LEACHING FACILITY: (type) 3-DrZ yt (.i G (size) i 0 A 3,X 2 t NO. OF BEDROOMS 3 i BUILDER OR OWNER T"(4rh/1-# C,,GcA1nJSJ PERMITDATE: `7416I6 ? COMPLIANCE DATE: '7r12FI1A 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 i i G 4 G3• � v^ r l 4 ,I Y� TOWN OF BARNSTABLE LOCATION 17 G .4 SEWAGE# VILJ,AGE k6a u.N f ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �bo`� ••.1 J LEACHING FACILITY: (type) )(b l� .f- (size) GXG w NO.OF BEDROOMS o2 BUII,DER OR OWNER 4L h . PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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� " s 5 J - l � ` � M � c1� SOIL TEST DATE OF SOIL TEST xJLY 21 2003__ SOIL TEST DONE BY j�Q WITNESSED BY OBSERVATION HOLE 1 ELEV.=_9887__ TOP OF FOUNDATION 20 FT MINIMUM FROM CELLAR PERCOLATION RATE < MIN./INCH AT 48 INCHES ELEV. _ 100•00 10 FT, MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE CLEAN SAND DEPTH HORIZ TEXTURE COLOR MOTT OTHER (ASSUMED) CONCRETE 0-7 A/P LOAMY SAND 10YR3/2 NO ROOTS COVERS 4" SCHEDULE 40 PVC PIPE LOAM AND SEED 7-22 B LOAMY SAND 10YR5/8 ROOTS _ MIN. PITCH 1/8" PER FT. 2" LAYER OF 22-132 C COARSE SAND 2.5Y7/4 15% COBBLES 1/8" TO 1/2" WASHED STONE N TREQUfRED 4" CAST IRON PIPE► O T-1 (OR EQUAL) MINIMUM �� PITCH 1/4" PER FT. FLOW LINE 10" ELEV. _ `� ❑ ❑ 0 ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ MIN. �,i r� " ° o / y LEVELO ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O O ° ELEV. _ _-- GAS ELEV. _ 6" SUMP ELEV. _ _ "�•� ° ° -- --= ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 2' o BAFFLE DISTRIBUTION ° O NO WATER ENCOUNTERED AT __132"_ ELEV. • _ 87.7 _ ELEV. _ ° ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ° o ° f �+ lflr2 ►�!:'f = 11,EYJr4�iN— LIQUID OUTLET �OX __� _ ° °° ° ° ° ELEV.J�EE • ` 4 FEET 14 INCHES (TEE TO BE PLACED ON FIRM BASE) TO BE WATER TESTED ? - 500 GALLSTONE IN AN WITH 5 FEET 19 INCHES IF MORE THAN ONE OUTLET DESIGN CALCULATIONS 6 FEET 24 INCHES 1000 GALLON 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE; r f. TRENCH FORMATION WELL NUMBER OF BEDROOMS 2��SI,Q_N 3 8 FEET 34 INCHES EXISTING 3/4' TO 1 1/2" CLEAN -� ZONE _ GARBAGE DISPOSAL UNIT _ NO _ SOIL ABSORPTION INDEX TOTAL ESTIMATED FLOW SEPTIC TANK DOUBLE WASHED STONE ADJUST__71,,-' ( 110 GAL/W/DAY X �_ OR.) _ 330_ GAL./DAY FREE OF FINES do SILT STEM SAS REQUIRED SEPTIC TANK CAPACITY _ 6QQ_ GAL. USGS PROBABLE WATER TABLE ELEV. = _ ACTUAL SIZE OF SEPTIC TANK _1QQQ GAL. SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ) ELEV. _ SOIL CLASSIFICATION _ NOT TO SCALE BOTTOM OF TEST HOLE ELEV. _ _ DESIGN PERCOLATION RATE <� MIN./IN. EFFLUENT LOADING RATE _Q14- GAL./DAY/S.F. LEACHING AREA __ __ SQ. FT. LEACHING CAPACITY (AREA X RATE) __'__� GAL./DAY RESERVE LEACHING CAPACITY �'___ GAL./DAY NOTES: 1 ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2 ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 98.2 r 4 ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL LEGEND: BE MORTARED 'IN PLACE. EXISTING r,OT ELEVATION xO.O 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH 98 8 EXISTING CONTOUR ----00---- DEEDED OR ZONING REGULATIONS. 06NER / APPLICANT IS TO 9 .2 FINAL SPOT ELEVATION 4 0. OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. FINAL CONTOUR — �0 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR SOIL TEST LOCATION 'p IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS UTILITY POLE PRIOR TO COMMENCING WORK ON SITE. G TOWN WATER =W —,W-- 7 CONTRACTOR IS TO VERIFY' GRADES AND ELEVATIONS AS WELL AS REA CATCH BASIN �Q� SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER .9 0, J20 S. F. f I 7 5 CESSPOOL OP GAS LINE G _ IMMEDIATELY. Q \ 9 LOAR ISL IS SHOIWNFON ASSESSORS MAP _ 271 AS PARCEL 98 9 BR 98.6 � CLEANOUT —ems C.O. _ 10p _ BR O � � o L,ONG RAW OF SAS - ` 99.1 I► ,�.4T. ' j a� - 0�3� TANYA s�°sue DAIGNEAULT v 8i�3 _ ' ) K/TC o No. 1095 I: APPROVED: BOARD OF HEALTH FL OR/DA 98.4 � ROOM0ROOM QECK 100.1\ DATE AGENT PROPOSED SEPTIC DESIGN `l&..98 4 FOR 98.2 W TAMMY GAGNON 99.2 �-� C7 98.0 17 Q p LOCUS ---- ----- ___ `'0 �98.9 O p ---- 7—� 1tp OO J rR—OJ* 176 BUCKW00D DR. N£O J 3 O r H 1 till i,IS MA _z : Q -' ROUTE 28 °° 3 _ of <r TADCO ENVIRONMENTAL CONSULTANTS p _ 26 COMPASS LANE, DENNIS, MA 02638 O p � (508) 385-2425 � p a > O O w Q L!AIJULY d 2003 SCALE 1 " = 20' U 1 p _Z O Q REVISED E! NO 2755 1 LOCATION MAP ( REVISED F!ifE—ET 1 QF� 1 C.- `S8�PROl,2467-00�dwgt2467-OO.DWC 0 T.A. DUMAS