HomeMy WebLinkAbout0160 CASTLEWOOD CIRCLE - Health 160 Castlewood-Circle, :.
Hyannis P
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No. C;b Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLation for nisposat 6pstem Construction Permit
Application for.a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 16.0 C4410,w OO d G%r c1n, Owner's Name,Address,and Tel.No. B ,(Xn (,Ohb
HyanrltS Assesso Ibo C0.414 Joed e,;ccl�i''.s Map/Parcel 2"1 Z S`1
Installer's Name;Address,and Tel.No. a#a E.ic cauc4iun Inc. Designer's Name,Address,and Tel.No. F W%ec % 4,nv�c�MQ
'3'iq...haU4.c, ISO PO 60Y 331 Hatw:0-% Ma. OZ(oyS
Type of Building:
Dwelling No.of Bedrooms Lot Size 0. 19 /acre 5 sq.ft.l� Garbage Grinder(N o)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other.Fixtures
Design Flow(min.required) gpd Design flow provided 3� gpd
Plan Date Number of sheets 2 Revision Date
Title
Size of Septic Tank 1000 00.k%0 n Type of S.A.S. (70 Soo oa Gho►rnboc3
Description of Soil 52,P— 01 atns
Nature of Repairs or Alterations(Answer when applicable) pldd MAO d-box and SAS Am 2a"uk*, k
I O O O. r imwoh UP 11, k-man
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 Certificate of
Compliance has been issued by this Board of Health.
Si Date 31AOIIO
Application Approved by . Date
Application Disapproved by Date
for the following reasons
Permit No. — Date Issued ?�
No. Fee /a
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 41
Yes
PUBLIC HEALTH DIVISION -`TOWN OF BARNSTABLE, MASSACHUSETTS
application for Bisposal 6pstetn Construction 3permit
-r Application for a Permit to Construct( ). ,Repaii(� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or L t'No. J to O Cep` !.i w o n r1 G .c t Owner's Name,Address,and Tel.No. C
k-1t nnr1�5• - •
Assessor's Map/Parcel Z t (c U i,cx'k i Z,,j6 o d L c c!
Installer's Name,Address,and Tel.No. ( ? ,c•a', ::� ;,c• Designer's Name,Address,and Tel.No.
-���I �lavt'[ ��U rjCnr1t.��:_j,�' 1'U (�caY j l 4•'CitW`C'`S N,(`t. 07-,
Type of Building: K
Dwelling .No.of Bedrooms Lot Size n. ► 2 A(r r'ti . sq.ftt! Garbage Grinder(N�
Other Type of Building. No.of Persons Showers( ) Cafeteria( )
s 4 .
Other Fixtures
Design Flow(min.required) •�n gpd Design flow provided gpd
Plan Date 3 14 12 l'i Number of sheets 2 Revision Date
Title
Size of Septic Tank Woo r,.11�� Type of S.A.S.
Description of Soil
y ,Nature of Repairs or Alterations(Answer kvhen applicable), 6r16 ..A :e
Date last inspectel ,rt k
Agreement: � !
The undersigned agrees to ensure the construction d maintenance of the afore described on-site sewage disposal system in �.
� I
accordance with the provisions,f Title 5,of the'Env irorunental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar/d of Health. ,
Signe Date*
Application Approved by Date o�6
Application Disapproved by a Date .
for thefollowing reasons
Permit No. io 4 I r ti Date Issued
THE COMMONWEALTH OF MASSACHUSETTS.••
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(J) Upgraded( )
Abandoned( )by �1 o
at 11.0 r „<�t„,.3 nn�i ( .1 has been constructed in accordance
with the provisions of Title 5 and the for.Disposal System Construction-Permit Nqa dated �c7•S �J
Installer 3 (l 4 7 Designer lT�;•r �.. t.
#bedrooms Z Approved design flow J c S t.l 91 gpd
The issuance of this permit hall no be construed as a guarantee that the system ed.
Date L. Inspector
- --
No. C� `� N, Fee
(/ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Vermit.
Permission is hereby granted to Construcf(' ) Repair(A Upgrade( ) Abandon( )
System located at e(40 n�,l la't�r'nrt
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty tdcomply 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 /7. c�-� Approved by t
Town of Barnstable
Inspectional Services
4
Public Health Division
BARMWABM
e� ' Thomas McKean,Director
o ° 200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:' 4-3- Zo Sewage Permit#ZOZO- o 90 Assessor's Map\Parcel 'Z`1Z- 5
Designer: CnUir a Mcr\i Installer: R i B EXemLi- - i o -
Address: 90. GOX 331 Address: iq 1r_a.5errLj rr#J
t
Nart��cl.` foresiota.lc-
On 3-Z6• ZO acousxA i on was issued a permit to install a
(date) (installer)
septic system at .1Go (2a:s lc.uj000(_ e,rct C__ based on a design drawn by
(address)
1QoLuC 0,3Lke.r c..r dated S- 13 20
(designer)
—L,-*"I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved, changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found-satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed i cor with the to rms of
the IXA approval letters (if applicable)
)AV C
n y f
X
taller's Si a No
esigner's Signatur (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE.PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
WoMdeptslHEALTH\SEWER connecASEPTIODesigner CeAification Form Rev 8-14-13.DOC.
Town of Barnstable
Inspectional Services Department
HA"XAS& E ' Public Health Division .
i639•
0 na+" 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4988 1616
February 10, 2020
MACPHERSON, DOUGLAS JOHN
160 CASTLEWOOD CIRCLE
HYANNIS, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 160 Castlewood Circle,Hyannis,MA was inspected on
01/30/2020 by Chad Hathaway, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
/
You are orderedto repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF T E BOARD OF HEALTH
omas McKea , R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\160 Castlewood Circle Hyannis.doc
�p41ME T�
p Town of Barnstable
HAR�ISfABLE,
,A 1639. ,• Inspectional Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-8624644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
aching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
t Commonwealth of Massachusetts 0?-7a — Orzf
�- - F .Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
160 Castlewood Circle
Property Address
Macpherson-Cobb
Owner Owner's Name
information is h annis V Ma 1/30/2020
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:out
forms
When
fillip out forms A. Inspector Information Sl t��y3leb
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not HPS
use the return Company Name
key.
Company Address
Forestdale Ma 02644
City/Town State Zip Code
�eoan 774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
1/30/30
specto s Sign re Date
The system inspector shall submi copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 da of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the i pector and the system owner shall submit the report to the appropriate
regional office of the DEP. he original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.M26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
PQX Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
_Information on care and do's and don't's can be found at town health dept or mass.gov
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The.system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson-Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s): The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is h annis Ma 1/30/2020
required for every —y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® 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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd:
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
p� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
❑ ® 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c� Commonwealth of Massachusetts
r - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hyannis Ma 1/30/2020
page. Cityr'rown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): record design Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in.this report.)
Laundry system inspected? ❑ Yes Z No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
I
l5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I .
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is h annis Ma 1/30/2020
required for every -y
page. CityrFown State ' Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
unknown
Were sewage odors detected when arriving at the site? ' ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 1.25'
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gal H10 tank full to cover inlet and outlet completely under heay scum layer. could feel conctete
baffles with prob. reccomended pumping tank to prevent a backup
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth: 12" +- bottom of tank
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
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? tape and sludge judge
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 baffles were not visable at inspection due to over loaded tank
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
I
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(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.):
no box
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
- p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson-Cobb
Owner Owner's Name
information is
required for every y h annis Ma 1/30/2020
page. City Fown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
I
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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
over loaded pit-wet soil
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
F
160 Castlewood Circle
Property Address
Macpherson-Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
pit is over loaded and backing up into tank. soil is wet. no ponding at ground level
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hY annis Ma 1/30/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is hyannis Ma 1/30/2020
required for every •
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
'r F
<`/6
r
0
'1P 9.0 Cl/
�2'
`-
t5insp.doc•rev.7Y26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 18
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson -Cobb
Owner Owner's Name
information is required for every hy annis Ma 1/30/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 16'
feet
Please indicate all methods used to determine the high groundwater elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
peerc test required
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Macpherson-Cobb
Owner Owner's Name
information is h annis Ma 1/30/2020
required for every —Y
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
INVOICE
CHAD HATHAWAY
P.0 Box 151 Forestdale Ma.02644
774 274 2581
HPSIONCAPE@YAHOO.COM
INVOICE# 1734
Massachusetts DEP septic Inspector DATE:2/5/2020
Title 5 Inspections=Emergency Services —Risers— Sewer Camera Inspections—Up Grades
Pipe and D-Box Repairs-System locating-Well Sampling—Pump and Alarm repairs
TO:COBB
160 Castlewood hyannis
DESCRIPTION HOURS RATE AMOUNT
Septic inspection 125.00
i
TOTAL 125.00
All work is to be completed in a workmanship like manner according to standard industry practices.Any changes or deviation to above
specifications described above by consumer may result in added labor and or material costs.All payments are due upon completion of work..
Payments over 30 days Late will result in interest charges at the maximum legal amount by law. Authorizing Signature agrees to terms
described above. Authorized Signature: Date:
Printed Name Date:
Please make checks payable to Chad Hathaway
THANK YOU FOR YOUR BUSINESSI
Septic System Inspection Report .
160 Castlewood Circle
1 H"s, Massachusetts
. N11ANh1� ..
March 30, 2004 `
Prepared For:
Andriues E. Uzpurvis
' 160 Castlewood Circle
Hyannis, Massachusetts 02601
{een Se _ Providing Innovative Solutions For- . .
�. Solid Waste %� Health &:Safety
Hazardous Waste 'iVC Environmental Monitoring
11.�n efi O Materials Management, . Compliance Qutsourcmg
www.greensealenvironmental.com
Phone: (508) 888-6034 Fax: (508) 88`8=1506
28 Route 6A, Sandwich, MA 02563
V-T I � ,3
COMMONWEALTH OF MASSACHUSETTS
tp EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
law
Sye
TITLE 5
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM___
PART A I
CERTIFICATION
Property Address: 160 Castlewood Circle,Hyannis MAR 3 1 2004
' Owner's Name: Andriues E.Uzpurvis TOvvN OF BARNSTABLE
Owner's Address: same as above HEALTH DEFT.
Date of Inspection: March 22,2004
MAP
Name of Inspector: (please print) Terry F.Bauer `----------n-��
Company Name: Green Seal Environmental,Inc. PARCEL
Mailing Address: 28 Route 6A LOT
Sandwich,MA. 02563
Telephone Number: (508)888-6034
' 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
i ' 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 /f
Inspector's Sig. natur 6— ex. Date: March 30, 2004
' The system inspector shall submit a co of`this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
The septic system Appeared to be in good functioning condition on the day of inspection.
Please note that the septic tank is in need of pumping.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
i
Page 2 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E.Uzpurvis
Date of Inspection: March 22,2004
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: The system appeared to be in good working condition on the day of inspection.
' 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.
1 Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
No The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
1 unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
' Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
' broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
No The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
1 pass inspection if(with approval of the Board of Health):broken i e(s)are replaced
PP P
obstruction is removed
ND explain:
1
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
' Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E. Uzpurvis
Date of Inspection. March 22,2004
' 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
1 is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
' _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
i
tPage 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
' Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E. Uzpurvis
Date of Inspection: March 22,2004
' D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to-each of the following for all inspections:
' Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
' — clogged SAS or cesspool
X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.)
' 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 serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
1 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 has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
' Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E.Uzpurvis
Date of Inspection: March 22,2004
Check if the following have been done.You must indicate"yes" or"no" as to each of the following:
j ' Yes No
X Pumping information was provided by the owner,occupant,or Board of Health(loot Available)
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) N/A
' X _ Was the facility or dwelling inspected for signs of sewage back up?
X ._ Was the site inspected for signs of break out?
' X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
X Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) 1310 CUR 15.302(3)(b)]
I
i
1 Page 6 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
' Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriucs E.Uzpurvis
Date of Inspection: March 22,2004
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 god
' Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
t Laundry system inspected(yes or no): N/A
Seasonal use: (yes or no): No
Water meter readings,if available(last 2 years usage(gpd):Unavailable at time of inspection.
Sump pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIALANDUSTRIAL N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sq ft,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: Not Available
' Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
' TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system(no"D"box present)
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
1 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:
Unknown date of system installation. No records found at Health Department or Building Department.
Were sewage odors detected when arriving at the site(yes or no): No
' Page 7 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E. Uzpurvis
Date of Inspection: March 22,2004
' BUILDING SEWER(locate on site plan)
' Depth below grade: 6" — --Other
.
Materials of construction: X cast iron 40 PVC other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
' No evidence of leakage,all joints appear to be in good condition on the day of inspection.
SEPTIC TANK: X (locate on site plan)
Depth below grade: W1
Material of construction: X concrete_metal_fiberglass_polyethylene
—other(explain)
' If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate)
Dimensions: 8.5'x 5' x 4' (1,000 gallon capacity)
Sludge depth: 3"
' Distance from top of sludge to bottom of outlet tee or baffle: 2'11"
Scum,thickness: 1'
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
How were dimensions determined: Direct measurement
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
' Tank is in need of pumping. Inlet tees(3) and outlet tee in good condition. No signs of leakage,liquid level at
outlet invert.
i
GREASE TRAP: N/A (locate on site plan)
' Depth below grade:_
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
' Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
1
' Page 8 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Castlewood Circle,Hyannis
' Owner: Andriues E.Uzpurvis
Date of Inspection: March 22,2004
' 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.):
1
1
Page 9 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Castlewood Circle,Hyannis
' Owner: Andriues E.Uzpurvis
Date of Inspection: March 22,2004
' SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
' If SAS not located explain why:
' Type
leaching pits, number: One 6' x 6' leaching pit(no evidence of stone found)
leaching chambers,number:
' leaching galleries,number:
leaching trenches, number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
' innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Soil dry,no signs of hydraulic failure,2 `of ponding,no lush vegetation,no root growth into pit.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
' Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
' Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
' Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: 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.):
f
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E.Uzpurvis
Date of Inspection: March 22,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
' benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
I '
Please see attached sketch
1
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' Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Castlewood Circle,Hyannis
Owner: Andriues E.Uzpurvis
Date of Inspection: March 22,2004
' SITE EXAM
Slope: Flat area
Surface water: None in area
' Check cellar: No water
Shallow wells: None in area
Estimated depth to ground water 32' feet(below the ground surface at the SAS)
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)
X Checked with local Board of Health-explain: Used town water level maps and information from 1992.
Checked with local excavators, installers-(attach documentation)
' X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
' High groundwater was determined by comparing USGS/Cape Cod Commission groundwater data and USGS
topographic data to Barnstable GIS information and field measurements.
' The surface of the ground at the SAS was obtained from the Barnstable GIS Department and found to be
elevation 67.3 feet above Mean Sea Level(MSL). The bottom of the SAS was measured to be approximately
7.5' below the surface;therefore,the bottom of the SAS is at elevation 59.8.
The groundwater elevation beneath the site area was measured by the Barnstable GIS Department in June of
1992 to be at an approximate elevation of 35.0 MSL. Using the Cape Cod Commission method to estimate the
' high groundwater elevation, the site was found to be within the Zone D area of indicator well A1W-230.
According to the data available from the Cape Cod Commission the June 1992 adjustment for that well is
7.9'; therefore,the adjusted groundwater is at elevation 42.9 MSL. When subtracted from the SAS bottom
(elevation 59.8)the resultant separation is 16.9' between high groundwater and the SAS bottom.
1 �
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L
LOCUS MAP & SEPTIC SYSTEM SKETCH
I
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Name:HYANNIS Location:
0• t 0•
D_ 00' Caption:
Septic System Sketch
' Castlewood Circle
#160
05
Septic
Tank
SAS
Cross Section
Ground Surface
' 11" 1291
7.5'
Foundation
' Septic Tank
SAS
Qo� -q
Location: 160 Castlewood Circle Fl ure 2
Hyannis, MAg Not To Scale
Date: March 23, 2003� Based on Visual Observations
4
�I
ti
DATE' ;_?/3/01-- - -
PROPERTY AOORESS: 160_ Castlewood Circle _
Hyannis,Mass. _ -
------------------------
-- 02601---
on the above dale, I In3pooted the eeptlo eystQ'M at the aboye addre33.
Thil syslem consl3la of the lollowing
1 . 1 -1000 gallon septic tank.
2. 1 -6 'X8 ' block cesspool.
8esed on my In3pecllon, I cerilfy the following oondltiona;
3. This is a title five septic system. ( 78 Code )
'4 . The septic system is in proper working order
at the present time.
S. The cesspool was dry at time of inspection.
6. The house has been vacant for some time.
7 . Replaced broken cesspool cover.
SICINATVRE., -
N
Company;�Jc� •�h_P:. N•c*wb.r_b Son , Ync ,
---Box- 66--------
_____
_CentsrYllleL. N6 ,- 04672-0066
Phone; 508- 77577338--_
THIS CIRTIFICATIOH OOeS NOT COHSTITVTE A OVARANTY OR WARRANTY
rzy
J6SE:PH P. MACOMBER & SON, INC.
&nki•Ovi►pool1•l91chIIfIdIPumptd 1• InitillodTown 3owir Connootiont
P.O. 66 ConlorYllk, MA 0263Z-0066
7753
JJ8 775bf1i
RECEIVED
JUL 3 0 2001
TOWN OF BARNSTABLE
HEALTH DEPT.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
i SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 160 Castlewood Ci r_rl e
1yannis,Mass_
Owner's NarneMilliam Clark
Owner's Address: P O Rax -41 S
Pf)r•aC'Sat t��86 nor
Date of Inspection:']/,:t.j c)1_
Name of Inspector: (please print) J^P. Macomber .Tr
Company Name:Joseph P. macomber & Son Inc
Mailing Address: Box 66
Centprvi 1 1 e Ma 07632
Telephone Number: 5o8-77S_v338
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:
ViPasses
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authoriry
_ Fails
' i nature: Date:
Inspectors S g
7 �D
The system inspector shall bmit�acopy 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
authoriry.
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 page I
Page 2 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: William Clark
160 as ewoo irc e
Owner: H annis,Mass.
Date of lospection: 7 3 001
Inspection Summary: Cbeck A,B,C,D or E/ALWAY complete all of Sectlon D
System Passes:
A)h_�11
y information which indicates that any of the failure criteria described in 310 CMR
15.303304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The system consists of 1 -1000 gallon septic tank.
1 -6 ' XR ' h1nrk cessrnnnl _ Cesspool is presentiy dry.Tne House
has been vacant for some time.
B. System Conditionally Passes:
.& One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
-4f 6 The septic tank is metal and over 20 years old' or the septic tun' (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exftltration 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 sepric 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:
AL AZObservation of sewage backup or break out or high LLcycl in the istribution box ue to broken or
obstructed pipe(s)or due to a broken, settled or uneverylistribution box.,System will pass inspection if(with
approval of Board of Health):
broken pipes)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
_obsavction is removed
ND explain:
2
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Page 3 of I I `
OFFICIAL INSPECTION.FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 160 Castlewood Circle
yannis, ass.
Owner: WilliamClark ----
Date of Inspection: 7 3 01
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,.safery or the environment.
I. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
—4 Cesspool or privy is within 50 feet of a surface water
_4Z Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the
system is functioning in a manner that protects the public health, safety and environment: .
The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple.
4& The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_4&The system has a septic tank and SAS and the SAS is less than 100 feet but 0 feet or more from a
private water supply%yell". Method used to determine distance f/iSf/�9
"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 anached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 160 Castlewood Circle
Hyannis,Mass.
Owner: Willaim Clark
Date of Inspection: 7 3 01
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
ischarge 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 bo bove outlet invert due to an overloaded or clogged SAS or
cesspool Vity
_ iquid depth in ccsspool is less than 6"below invert or available volume is less than 'Aday flow
Required pump ing more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped �.
y 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 ponion of a cesspool or privy is within a Zone I of a public well.
�/ y 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. (Tbls 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 S ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.(
A49 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CM 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
!� system is within 200 feet of a tributary to a surface drinking water supply
sensitive area Interim Wellhead Protection Area— IWPA or a mapped
_ the system is located m a nitrogen sens ( ) PP
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
..Yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 160 Castlewood Circle
Hyannis,Mass.
Owner: William Clark
Date of Inspection: 7 3 / 01
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,Xuding 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 ?
z _ Was the facility owner(and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
Determined in the.field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 160 Castlewood Circle
Hyannis,Mass.
Owner:William Clark
Date of Inspection: 7 3 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms):��=��
Number of current residents: 0_
Does residence have a garbage grinder(yes or no): N
Is laundry on a separate sewage system ( es or no):�JM (if yes separate inspection required)
Laundry system inspected(yes or no):
�
Seasonal use: (yes or no): Al �
Water meter readings, if available (last 2 years usage(gpd)):/UO �5;zo4gt F-w y'ors
Sump pump(yes or no):_6.20
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: /g
Design now(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):42
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): AM
GENERAL INFORMATION _
Pumping Records
Source of information: '_y�LZ4A
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, , soil absorption system
/TV Single cesspool
Overflow cesspool
XZ 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)
C6 Tight tank /A Attach a copy of the DEP approval
Other(describe): _ 1164
Approxima ee of all components, date installed(if known)and source of information:
1� -
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 160 Castlewood Circle
Hyannis,Mass.
Owner: William Clark
Date of Inspection: 7 3 01
BUILDING SEWER(locate on site plan)
�1
Depth below grade:
Materials of construction: ast iron,f/ 40 PVC Zther(explain): 644ei
Distance from private water supply well or suction line: Oa '
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints a s
`&-'6"14 S vented through the house vent.
SEPTIC TANKt)(locate on site plan)
�l
Depth below grade: 0
Material of construction: !/concrete&Lmetal4�jfiberglass4lb polyethylene
,120other(explain) .V
I f tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no)ro l (attach a copy of
certificate) t/ I , tt
Dimensions:
Sludge depth: ��_
Distance from top_gisludge to bonom of outlet tee or baffle:
Scum thickness:Z4a<o1-f_f
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet inven, evidence of leakage,etc.):
Pump the septic tank every 2-3 years_ Tn1Pt P, Outlet tees
are in place_The tank ; s strt,r-t,lraIIy sound and—shows no
evidence of leakage.
GREASE TRAPocate on site plan)
Depth below grade:.(�4
Material of construction4ey—concreteO meta�fiberglassA;l�polyethylene/bother
(explain): I4
Dimensions: 116
Scum thickness: WX
Distance from top of scum to top of outlet tee or baffle:lQ_
Distance from bonom of scum to bottom of outlet tee or baffle:
Date of last pumping: j)4
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 trap is not present.
7
Page 8 of I I
OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Castlewood Circle
Hyannis,Mass.
Owner: William Clark
Date of Inspection:, 7/3/01
TIGHT or HOLDING TANK4—(tank must be pumped at time of inspect ion)(]ocate on site plan)
Depth below grade: Ali
Material of construction: ,eJA concrete metal IzA fiberglass&A polyethyleneV.4 other(explain):
AU
Dimensions: Vyt
Capacity: gallons
Desien Flow: W14 gallons/day
Alarm present(yes or no):
Alarm level: V4 Alarm in working order(yes or no): 4)4
Date of last pumping: . 4J,4
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOXl1�ye-(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.):
Distribution box is not present
PUMP CHAMBER/{lL(locate on site plan)
Pumps in working order(yes or no): NA
Alarms in working order(yes or no): .411
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present.
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Castlewood Circle
Hyannis,Mass.
Owner:William Clark
Date of Inspection: 7/3/01
SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan,excavation not required)
If SAS not located explain why:
Located
T e yTD leaching pits, number: O
.z/P leaching chambers, number:
t)Q leaching galleries,number: a
leaching trenches,number, length: Q
ALOJe9ching fields,number,dimensions: Q
Y overflow cesspool,number: t �`�e ���---- �+ �
innovative/alternative system Type/name of technology://j J'l!/e, zO C.c4 ,�
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic
failure or ponding.Soils are dry, Vegetation is normal
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 laver:
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.):
Same as ahovP
PRIVY/.1�e(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: WW
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy is not present.
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:1 60 Castlewood Circle
yannis, ass.
Owner:William ar
Date of Inspection:
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.
. o
10
Page 11 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,C
SYSTEM INFORMATION (continued)
Property Address: 160 Castlewood Circle
yannis, ass.
Owner: William Clark
Date of Inspection: 7 3/01
'SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
r
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
tans on record - If checked, date of design plan reviewed:
40bes!eed site (abutting gropeP
bservation hole within 150 feet of SAS)
cke wit oca oar o th-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water contours Map.
Gahrety & Miller Mndpl
12 16 94
11
a
`.i•rrnr .-n'r�rTrtrnrRlr•IrtnTnr rnrnrRR+rn►TRA1.nn�rs1Y+<w►�r11R TT.'.Tr T:•Ir-:..z..r •,
1 TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACF SEWA(;F ()ISr'OSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
- i••1•T••.•::t-T.t1I.�.TTTTr'11'1f.Tr1 ^I/Jfnf/TrT7R•�—t•1"1�'�1'R�T�►IR�It�7R7 A1/1 •TI`T'IT1. �. w
-TYPI OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRES$ 160 Castlewood Circle Hyannis,Mass.
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME William Clark
PART D - CERTIFICATION
NAME OF INSPECTOR _Joseph P. Macomber Jr..
COMPANY NAME Joseph P. Macomber V ion Inc
COMPANY ADDRESS Box - 66 Centerville Ma 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 ) 775 _ 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
ID
his address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
ecoinmendationS regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
• u i 11 ;+ 1,
Chec one ;
..-Z-/
V System: PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Lhe environment as defined in 310 CMR 150' 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ..
System FAILED*
The inspection which I have con tcted has found that the system fails to
protect the jitiblic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection orm ,
Inspector Signature 1.4 1/ Date
ane' copy of thisfication must be provided to the OWNER, the BUYER
here applicable ) and the 130ARD OF HEALTII.
• If the inspection FAILED , the owner or operator shall upgrade • the system
within one ,year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y p
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 filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: ,
key to move your
cursor-do not David D. Coughanowr, R.S. U
use the return Name of Inspector
key.
Eco-Tech Environmental Q �
Company Name ti
43 Triangle Circle
Company Address t O
Sandwich MA `02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number =j
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority :
Z.-4 � P--� April 25, 2012 t
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system 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.
d P 2)
l5ins•11/10 Title 5 Official Inspection rm ubsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601
required for every Y April 25, 2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
Removal of grinder is recommended
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):
r
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is rll 25, 2012 Hyannis MA 02601 A required for every y p
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
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
l5ins•11/10 Title 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
�M 160 Castlewood Circle
Property Address
Lucy J. Buckley `
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y P
page. Citylrown 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 '/z day flow
15ins-11/10 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
160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y P
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ins•11/10 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
M 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25 2012
required for every y P
page. City(rown 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): n/a Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a - no plan
t5ins•11/10 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
M 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 April 25, 2012
required for every Y P
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
No plan was found at town offices.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 114 gpd
9 ( Y 9 (gP ))�
Detail:
2010, 2011
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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):
Septic Tank and Leach Pit
t5ins•11/10 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
w„ 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every - y _ P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age of system unknown -no design plan was found at Health Department.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
Z 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
8.5 x 5 x 6- 1000 gallon tank
Dimensions:
Sludge depth: 5 in
t5ins•11/10 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
160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601
required for every Y April 25, 2012
page. Citylrown 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 29 in
Scum thickness 5 in
Distance from top of scum to top of outlet tee or baffle 7 in
Distance from bottom of scum to bottom of outlet tee or baffle 12 in
How were dimensions determined? previous inspection report
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level at outlet invert. Maintenance pumping is recommended within one year and every 2 years
after that. Tank and tees appear structurally sound and functioning as intended. No evidence of
leakage in or out was observed.
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
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 A rll 25, 2012
required for every - y P
page. Cityrrown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
µ 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every P
page. Cityrrown 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
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 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
M 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y P
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:
❑ 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.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found half full.
No staining at cover interface or in overlying soils was observed.
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
(Sins-11/10 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
160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every P
page. Cityrrown 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.):
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal system Form -Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA .02601 April 25, 2012
required for every -Y
page. Gitylrown State, Zip Code Date of Inspection
D. System Information (cost;)
Sketch Of Sewage Disposal System: Provide`a.view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
0 drawing attached separately
o � "
w
Chi �� oai� C L ��
t5ins•11110 Tillo 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601
required for every Y April 25, 2012
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: 30+feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Previous inspection report
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 30 feet above
groundwater table. Previous inspection report indicates high groundwater is 32 feet below the
surface.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 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
�M 160 Castlewood Circle
Property Address
Lucy J. Buckley
Owner Owner's Name
information is Hyannis MA 02601 Aril 25 2012
required for every p
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATIQN S t1fF W 0 6 C-41ad E SEWAGE #
VILLAGEa1/A-N Ni S ASSESSOR'S MAP & LOT 2 2 �o-
INSTALLER'S NAME&PHONE NO. LA^J kiVO WfJ
SEPTIC TANK CAPACITY 110.000 g !Q- e,4 S
LEACHING FACILITY: (type] L��� )fi (size) G�x 6r Leos-b,.jr-0
NO.OF BEDROOMS 2
BUILDER OR OWNER _ d A-+LEES u'40L,(Lv;S 6-w-
PERMIT DATE: L1 nJ"o wl/ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility )(at / Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N f4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist �,/ Feet
within 300 feet of leaching facility)
Furnished by TE"�/ 6 - 6a&g J Sao
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TOP OF FOUNDATION COVERS TO.BE WATERTIGHT AND SEPTIC SYSTEM PROFILE Flaherty Environmental Services
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EL. 58.0' EL. 55.0' INSP. PORT W I 3" OF GRADE �"
CLEAN SAND P.O. Box 331
2" of's" to"" DOUBLE;WASHED EL. 56.0' Harwich, MA 02645
PEASTONE OR GEOTEXTILE 774.994.1166
4" CAST IRON or EQUIVALENT FILTER FABRIC
MIN. PITCH 1/4" PER FOOT
4"SCHEDULE 40 PVC PIPE 4"SCHEDULE 40 PVC PIPE
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'•Z '•�• .: MECHANICALLY COMPACTED (2) SOO GALLON H-20 CHAMBERS
1000 GALLON SEPTIC TANK WITH 4'STONE AROUND IN A 5.5'
(DATUM: ASSUMED) (EXISTING) 3n to 1b" DOUBLE WASHED STONE
a 2 12.83'X 25'X 2' CONFIGURATION EL.
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45.5' USGS ADJUSTMENT: N/A LOCATIONMAP
GROUNDWATER ELEV: N/A
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SITE AND SEWAGE PLAN
LEGEND V 7.47'. TH-lY FOR
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REP LCP 24349-B PAGE 1 OF2
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....................................—........... ..... ....-......................... .... ... -..............................................................................--__----.... ...................................................... ....- ..... .............................................................................................................__ ............................................................ -_—...................................
Flaherty Environmental Services
GENERAL NOTES DESIGN CALCULATIONS SYSTEMDETAIL
TION BOX AND ANY COMPONENTS NUMBER OFACTUAL BEDROOMS 2(DESIGN FO k 3) 774.994. 1166 .
DISTRIBU
ANTICIPATED VEHICULAR
WITH ANY
TRAFFIC TO BE H-20 RATED. GARBAGE DISPOSAL UNIT NO
2. THE DESIGN OF THIS SYSTEM DOES NOT
REQUIRED SEPTIC TANK CAPACITY 440 GAL.
4. ALL CONSTRUCTION TO CONFORM WITH
SIZE OF SEPTIC TANK 1000 GAL. (EXISTING)
APPLICABLE LOCAL, STATE AND FEDERAL
CODES AND REGULATIONS. SOIL CLASSIFICATION
VERIFY ALL ELEVATIONS AND DETAILS AND
REPORTANY DISCREPANCIES TO
DESIGNER PRIOR TO CONSTRUCTION OR 12,83'
ASSUME ALL RESPONSIBILITY
LEACHINGAREA
FOR MAINTAINING SAFE WORK AREA, 25.O'x 12.83' =320 SF
PRIOR TO CONSTRUCTION.
Z ANY CHANGES TO OR DEVIATIONS FROM INA 12.83'X25'CONFIGURATIONAS DIAGRAMMED
THIS PLAN MUST BE APPROVED IN
WRITING BY FLAHERTY ENVIRONMENTAL
RESERVE LEACHING CAPACITY NIA
SERVICES AND LOCAL BOARD OF HEALTH.
8. FINISH COVER OVER COMPONENTS IS NOT
SHOWN PER PLAN.
9. ALL ABANDONED SEPTIC SYSTEM
COMPONENTS TO BE PUMPED DRY AND
FILLED WITH CLEAN SAND OR REMOVED
AND REPLACED WITH CLEAN SAND.
10.ALL COMPONENTS TO BE PROVIDED WITH SOIL EVALUATION
WATERTIGHT ACCESS PORTS WITHIN 6" OF TESTHOLE#1 TPT#20-038
FINISH GRADE. Evaluator- David D Flaherty Jr,RS,REHS
11.ALL SEPTIC TANKS, DISTRIBUTION BOXES BOH Witness: David Stanton,RS SE#2755
AND PIPING TO BE INSTALLED Date: March 13,2020 BOH Witness: David Stanton,RS
WATERTIGHT
12.NO KNOWN WETLANDS OR WELLS WITHIN TH-I ELEV 56.0'
150 FEET OF PROPOSED LEACHING. 0.
13.THIS IS NOT A CERTIFIED PLOT PLAN AND 0"-9"A LS IOYR312
NITAVRO
UNDER NO CIRCUMSTANCES IS THIS PLAN
TO BE USED FOR ZONING OR BUILDING
14.LOTIS SHOWN AS ASSESSOR'S MAP272
7 cerfify that on November 12,2002, have passed
ATED WITHIN AN
15.LOCUSPROPERTYIS LOC PERC AT 48" SITE AND SEWAGE PLAN
the examination approved by the Department of FOR
Environmental Protection and that the above analysis
AQUIFER PROTECTION DISTRICT(ZONE II).
has been performed by me consistent Wth the B & B EXCAVATION, ZNC-1
required training,expertise,and expedence desclibed
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