HomeMy WebLinkAbout0191 BUCKWOOD DRIVE - Health 191 Bu,dkwood Drive`
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TOWN OF BARNSTABLE V'
LOCATION ! ` �11CI'r Zt�"70J Ole SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
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I 'S NAME, & PHONE NO. A & B CMM 775-6264
-SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNE
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DATE P RD: d '� 7 �'
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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SEPTIC TANK CAPACITY "N I
LEACHING FACILITY: (type) (size) r�)<X
NO.OF BEDROOMS
BUILDER OR OWNERNJ
Gr ec�vy
PERMITDATE: 2-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
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Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't a 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name/
information is Hyannis / MA 02601 3/28/16 r
required for every y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Richard T. Johnson
use the return Name of Inspector
key.
D&J Environmental Services
� Company Name
P.O.Box 764
Company Address
Buzzards Bay MA 02532
Citylrown State Zip Code
508-735-8740 S113545
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 a Local Approving Authority
3/28/16
I ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
<L'� ACommonwealth of Massachusetts
Nsw Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is.imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating.that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owners Name
information is required for every Hyannis MA 02601 3/28/16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is Hyannis MA 02601 3/28/16
required for every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El Z Any portion of a cesspool or privy is within 50-feet of a-private water supply well.
0 ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall-upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r� 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined?(If they were not
® ❑ available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220GPD
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
1 �I
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Presently
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
' Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3128/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Presently
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
® Other(describe):
1000 Gal septic tank, leach pit, 4 shallow infiltrators
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1997 per disposal works permit
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
®cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line 400+: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
joints structurally sound, no signs of leakage .
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. 8.5'x 5'x 5'
Sludge depth:
5" i
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Field measure/MFG Specs.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Concrete baffle in good condition, tank structurally sound, no evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner owner's Name
information is Hyannis MA 02601 3/28/16
required for every y
page. CitylFown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
"If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is Hyannis MA 02601 3/28/16
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
4-diffusers
❑ 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.):
no signs of hydraulic failure, no damp soil, normal vegetation.
f
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Titte 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
0 hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
AsBuilt Page 1 of 1
C TOWN OF BARNSTABLE
LOCATION !I ,O V< r .ZV'"D. Of , SEWAGE#
VILLAGE {
ASSESSOR'S MAP& LOT
�.v5 Af vies
IT'S NAME PHONE NO. A & B CANC'0 175-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO:OF BEDROOMS . PRIVATE WELL OR PUBLIC WATER
BUILDER O WNB �f 6 i fVy /1°19&.,'T
/.vSP �
DATE D: `a 7: o/
DATE COMPLIANCE-ISSUED:
VARIANCE GRANTED: Yes .NO
! j
o
r
93-Y
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=271117&seq=1 3/28/2016
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 13+feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: 1997
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:
Obtained from site observation, visual elevation, disposal works permit dtd 1997 on file with BOH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ti 191 Buckwood Dr.
Property Address
Laurie W. Holzworth
Owner Owner's Name
information is required for every Hyannis MA 02601 3/28/16
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17
. Z ► o�
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP ` I
PARCEL '
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
- ;7,7VED
Property Address: 191 &4ckyza,,,,k Dr-
Owner's Name: Ric,, �� 2 7 2003
Owner's Address: i ll I Riu L 1 L-aG-)
/arc C)3 TGti'. . - b"vaiTABLE
Date of Inspection: HEALTH DEPT.
Name of Inspector: lease print)
Company Name:
Mailing Address:
Telephone Number: — 3
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 2A 6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heahh.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 '
****Tt ;report only describes conditions at the time of inspection and under the conditions of use at that
time.T ,inspection does not address how the system will perform in the future under the same or different
coedit j of use.
Title 5: )ection'Form 6/15/2000 page 1
ti
_ Page 2,of I I
OFFICIAL INSPECTION FORM- SE
NOT FOR VOLUNTARY ASSSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ m) T),r
Owner:
Date of Inspection: ,
Inspection Summary: Check A,B,C,D or E/ LWAYS complete all of Section D
A. S stem 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 Condi 'onally Passes:
One or more sys components as described in the"Conditional P s"section need to be replaced or
repaired.The system,upon ompletion of the replacement or repair,as roved by the Board of Health,will pass:
Answer yes,no or not determined ,N,ND)in the for the f lowing statements.if"not determined"please
explain.
The septic tank is metal and over ears old*or septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or filtration o failure is imminent.System will pass inspection if the
existing tank is replaced with a complying sep 'c tank approved by the Board of Health.
*A metal septic tank will pass inspection if it is ally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ailable.
ND explain:
Observation of sewage backup o reak out or high tic water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, ttled or uneven distrib tion box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or repl ed
ND explain:
The syste equired pumping more than 4 times a year due to broken or structed pipe(s).The system will
pass .inspection' (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND ..)lain: .
i
2
Page 3 of 11 r.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME fS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORN
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspect21
C. Further Evaluat' a is Required by the Board of Health:
T— Conditions exist why require further a cation by the Board of Health in order to determine if the system
is failing to protect public heal afety or environment.
1. System will pass unles and ea
determines in accordance with 310 CMR 15.303(1)(b)that the
system is not fun . ning in a mann which will protect public health,safety and the environment:
_ Ce ool or privy is within 50 feet of a surface water
esspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fai unless the Board of Health(and Public Water Sup tier,if any)determines that the
system is functioning a manner that protects the public health,s and environment:
_ The system has a se 'c tank and soil absorption syste AS)and the SAS is within 100 feet of a
surface water supply or tribu to a surface water sup
_ The system has a septic tank SAS and t SAS is within a Zone 1 of a public water supply.
The system has a septic tank and S d the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank d SAS and t SAS is less than 160 feet but 50 feet or more from a
private water supply well". od used to determ distance
"This system asses if a well water analysis, erform t�P y ,p ed a DEP certified laboratory,for coliform
bacteria and volatile ganic compounds indicates that the well i ej from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or ess than 5 ppm,provided that no other
failure criter' a triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: H 1 9 k�;CQ �,•
Owner: 1
Dated!Inspection.
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
7 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
-Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a.large s tem the system must serve a facility with a ign flow-of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or' "to each of the following:
(The following criteria apply to large sy ms in addition to a criteria above)
yes no
_ the system is within 400 feet of a s ace ' ing water supply
the system is within 200 fe of a tributary to a s ace drinking water supply
_ the system is locat in a nitrogen sensitive area Qnte ' Wellhead Protection Area—IWPA)or a mapped
Zone II of a pu c water supply well
If you have answ ed"yes".to any question in Section E the system is consi red a significant threat,or answered
"yes"in Sectio D above the large system has failed.The owner or operator o y large system considered a
significant threat.under Section E or failed under Section D shall upgrade the syst in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Dep ent.
4
�
Page 5 of 11 'Ej t j.
� JSn f
. rI
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR]
PART B
CHECKLIST
Property Address: --I) yowd", -1,9
Owner:
Date of Inspect on:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
if 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?
as the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
V/ 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:
je,�n o
_ _ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
rage o of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: (? 1
Owner' 1
Date of Inspection.
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design):_L Number of bedrooms(actual): o�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:_-1�,___
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):e[if yes separate inspection required]
Laundry system inspected(yes or no):1A
Seasonal use:(yes or no): tlJ 0
Water meter readings,if available(last 2 years usage(gpd)): pal
Sump pump(yes or no):►�O
Last date of occupancy: r
COMMERCXS
USTRIAL
Type of estab
Design flow( 310 C 15.203): Lmd
Basis of desigts/ sons/sgft,etc.):
Grease trap pr o):_Industrial wastank esent(yes or no):
Non-sanitary harged t e Title 5 system(yes or no):Water meter rf available:
Last date of occupancy/use:
OTHER(describe):
Pumping Records
GENERAL INFORMATION
r
Source of information:_ r,
Was system pumped as part of the' spe tion(yes or no):
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYKE OF SYSTEM
V Septic tank,dia ,soil absorption system
_Single cesspool
Overflow cesspool
_ivy
_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 components,date installed(if known),and source of' formation:
4 4-
Were sewage odors detected when arriving at the site(yes or no): �
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: `r
Date of Inspecti n:
BUILDING SEWER(locate on site plan)
Depth below grade: _
Materials of construction:,2!�-cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: 'l I
Comments(on condition of joints,venting,evidence of leaka8a,etc. :
)
SEPTIC TANK:Zoocate on site plan)
Depth below grade:
Material of construction: V concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: "
Distance from top of scum to top of outlet tee or baffle: I I
Distance from bottom of scum to bottom of outlet tee or baffle: 151,
How were dimensions determined: 7q }-
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
GREASE P:_(locate on site plan)
Depth below grade.
Material of construction.\ co rete_metal fiberglass_polyethylene_other
(explain): _
Dimensions:
Scu/thickness:
Distof scum to top of ou tee or baffle:Distttom of scum to bottom o tlet tee or baffle:
Dateing:Commping recommendations,inlet an utlet tee or baffle condition,structural integrity,liquid levels
as ret invert,evidence of leakage,etc.):
7
Page 8 of l l
OFFICIAL INSPECTION FORM-NOT I'OR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:ACI j
Owner: .
Date of inspecti n: lbl
TIGHT or HOL%NGTANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grad
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: ons
Design Flow: Rallo
/day
Alarm present(yes or
Alarm level: Alarm in working or r(yes or no):
Date of last pu ing:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION Ian BOX: (if present must be opened)(locate on site
plan)
Depth of liquid level abo a outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: KonPumps in working order(Alarms in working order(Comments(note condi ' ndition of pumps and appurtenances,etc.):
g
• Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: h') �Q (-
Owner:
Date of Inspec ion:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T�leachin its,number: '00O
gP _
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
inn ovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: cesspool mus pumped as part of inspection)(locate on site plan)
Number and configuration.
Depth—top of liquid t let ert:
Depth of solXIa
Depth of scuDimensionsool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: ( ate on site plan) `
Materials of constructio ,- '
Dimensions:
Depth of solids:
Comments condition of soi, igns 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:
Owner:
Date of Inspec ion: i2226103
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.
5Gv-sc%��k O�c sr.Er o
Iwo GA, ��I- , S 3a J .4
AD
R�R 8
I0
' Page 11 of 11 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: `1
Owner:
Date of Inspect n: a
SITE E
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _feet C
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
- , Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
` i7rr "J 1 � ��,•wToY 5 �Ip (�'' Y I�eB
3 �
r
11
RECEIVED
COMMONWEALTH OF MASSACHUSETTS
x EXECUTIVE, OFFICE OF ENviRONMENTALAJ'FAW 0 2 2001
a d DE, PARTMENT OF ENVIRONNII NTAL PRO EI VPF�
TO ARNSTABLE
HEALTH DEPT.
350 MAIN STREET
WEST.YARMOUTId,MA
�® 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 191 BUCKWOOD DRIVE
IIYANNIS,MA 0260E
Owner's Naive: ROGEAN,ROBER-r
Owner's Address: 191 BUCKWOOD ROAD
"IIYANNIS,MA 0260E
bate of Inspection 1`12',131MARY 27,2001
Name of Inspector:(please print) DAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarnioutli,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 2-27-01
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 subnm the report to the
appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot
lie buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection Form 6/15/2000 1
S i
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
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: N/A
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 complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
C. Further Evaluation is Required by the Board of Health: N/A
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 CN M 15.303(l)(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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"* This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
I
Title 5 Inspection Form 6/15/2000 3
I
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in leaching is less than 6"below invert or available volume is less than''/�day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above) .
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone H 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3Xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 314 CU.FT./2000 426 CU.FT.
Sump pump(yes or no) NO
Last date of occupancy: UNKNOWN
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alterative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
AGE OF SYSTEM UNKNOWN.NEW LEACHING INSTALLED IN 1997 PERMIT#97-502
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 8"
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 3"
Distance from top of sludge to the bottom of outlet tee or baffle: 27"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL. TANK AND COVERS 8"BELOW GRADE.OUTLET TEE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
I
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 1
X leaching chambers,number: 4
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.)
OLD LEACHING IS ONE(1)1,000 GALLON PRE CAST PIT.ONE LINE IN,NO TEE. ONE LIEN OUT WITH
TEE.NEW LEACHING IS FOUR 94)HIGH CAPACITY INFILTRATORS. NOTE:PROBED AROUND
INFILTRATORS-DRY.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBElU
Date of Inspection: FEBRUAIZY 27,2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locale all wells within 100 feet. Locate where public water supply enters the building.
id y .,
at;
Title 5 Inspection Form 6/15/2000 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: 191 BUCKWOOD DRIVE
HYANNIS,MA 02601
Owner: ROGEAN,ROBERT
Date of Inspection: FEBRUARY 27,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 25.1 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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA: WELL AIW 230,25.F
BOTTOM OF LEACHING INFILTRATOR 4',BOTTOM OF PIT 7' 8",USGS WELL DATA
GROUND WATER AT 25.1'.
Title 5 Inspection Form 6/15/2000 11
.r No. ! l✓ Fee J
THE COMMONWEALTH OF MASS USETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARN ABLE,, MASSACHUSETTS
0(ppYication for Mtgogar *p5tem Construction 3permit
Application for a Permit to Construct( )Repair( grade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. %6k 1 )
e-lLic=A,� H-W 4-5 Owner's Name,Address and Tel.No.
ry�f�f,� ���p �o�ewv
Assessor's Map/Parcel C I l /
Installer's Nye,Address,and Te1.N0 S Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms�_ Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow a—CIO gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank SsTe' — \000 5k.�t Type of S.A.S. RA2 �' tCF�-��3�'2S
Description of Soil C
Nature of Repairs or Alterations(An wer when applicable) SwGA PA
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b of Health.
Signe Date
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued �=
TOWN OF BARNSTABLE
LOCATION '-X4UXVb Orya� SEWAGE # '7`50S'
VILLAGE ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY yn yo-W 4!y = l F�Gb 4ti41\u�.
LEACHING FACILITY: (type) W `.Ccc 't(,z �A. (size).',NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 9 /b 2-2—COMPLIANCE DATE: 9 Z z cJT—
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
P
M
3
n
t
o
J
.. No. �� `��2 e�, Fee �CJ!(
`
THE COMMONWEALTH OF MASS USETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNS ABLE., MASSACHUSETTS Yes
2pplication for Xkzpaar bpgtem (Construction Permit
c Application for a Permit to Construct( )Repair(Vpgrade( )Abandon( ) ❑Complete System ❑Individual Components
LocAtion Address or Lot No. \q '&C A )ODO 7 rxw 4S Owner's Name,Address and Tel.No.
- iv dab �o�'ewV
Assessor's Map/Parcel
Installer's N e,Ad ress,and Tel o. S Designer's Name,Address and Tel.No.
k06 50,��- !
Type of Building:
Dwelling No.of Bedrooms_�_ Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( )" Cafeteria( )
Other Fixtures
Design Flow of gallons per day. Calculated daily flow �3LAC1 gallons:
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank gtK`ST \C70O 5ra�(�� Type of S.A.S. � ziT�, -i�
Description of Soil SA-0
y41
Nature of Repairs or Alterations(An wer when applicable) Tt-S1 O'k X2&hc 1�'I h t C114
(ti 5'1�cuf' b�i�tG eKlSi��
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b f Health.
J 4 -�Signe Date
Application Approved be"',-
Date s
Application Disapproved for the following reasons
�f! r
Permit No. '' � � � �e`' �-}�''~�" �`' Date Issued r'
----- ----- ' sf ----------------=--
-- lam;,,•w....:_ -..
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CER ,thitt the On-site Sewa a Disp sal System Constructed( )Repaired( )Upgraded( I�
Abandoned( )by
at C. \: DD V h,t has been constru ed in accor nce
with the provisions of Title 5 and the for Disposal System Con tructio ermit N dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.t Date Q _ ", -1 Inspector
N.. qJ7- 1 Few_!!�o 0�0
�i THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mizpooar *pttem construction Permit
Permission is hereby granted to Construct( ) epair( )) grade( )Abandon( )
System located at _ t.t C. W O O \)-jL, t C 6\r
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 completed within three years of the date of this it.
Date: '� �"" Approved b
f NOTICE: This Form is to he used for thc.Repair of Failed • • ' '~
Septic Systems Only
CEWFIFICKHON Of SKETCH AND'API'LICATION FORA DISPOSAL
IVU1thS (,UNS'rItUC'I IUN I'hltn1rr(1yl'I'IIUU'I' I)ESILNED !!ANSI
f 2vV �__, hereby certify that the application for disposal works Jt
construction permit signed by me dated (A -6,—J 7 concerning the
meets all of the
property located atfollowing criteria: .
There are no wetlands within 300 feet or(he proposed septic system
• There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no increase in now and/or change In use proposed
• There are no variances requested or needed.
SIGNED: DAM
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAttach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submiticdl.
I
C