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HomeMy WebLinkAbout0172 CASTLEWOOD CIRCLE - Health 172 Castlewood Circle - Hyannis CP%R- � i 272'034 i !) e o f a o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cdyrrown 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 A. General Information Y4 forms on the computer,use 1. Inspector: ry only the tab key cam; to move your T(VI , Q DOUGLAS A BROWN cursor-do not tip^ 4 use the return Name of Inspector key. DOUGLAS A BROWN INC -c Q x Company Name _ P.O. BOX 145 Company Address CENTERVILLE MA ~'� t Vfi-�I Cityrrown 02632 State Zip Cede - 508-420-4534 - S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/10/10 nspe s Signature Date _ �r 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. (Sins•09I08 Title S Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 I r T` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Properly Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 every page. Cltyrrown Date of 0 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: SEE ATTACHED PAPER WORK SEPTIC TANK IS IN A EASMENT 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 forges", "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): lsins•osoa Title 5 Official Inspection Foos: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 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cdyrrown 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 t51ns•09A8 Title 5 Official Inspection Forth: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 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cltyrrown 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 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 dogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , - ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow t5ms•09M Title 5 Official Inspection Form:Subsurface Sewage asposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. tsins•osma Title 5 Official Inspection Form:SubsuRace Sewage Disposal System•Pape 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Properly Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 tsins•osoa Title 5 Official Irrspectlon Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 every page. Clty/Town 5/10/10 State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK IN EASMENT A D-BOX AND 3 CULTEC CHAMBERS IN A 8X23 AREA Number of current residents: 3 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 years usage(gpd)): 08-187/09-156 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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-091138 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 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 every page. Cltyrrown Date/10 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: SCOTT FRANK PUMPED IN 2009 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): I tsins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page a of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: S.A.S INSTALLED IN APRIL 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ .Yes ❑ No Dimensions: 1000 GALLON Sludge depth: 2" t5ins•0901 Title 5 Official Inspection Form:Subsurface Sewage Disposal 8 Po System•Pape 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness TRACE 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? WOODEN POLE 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 LOOKS FINE AT THIS TIME Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 15ins•09A8 Title 5 Offirial Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 r O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 y El 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•as oe Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 17 r I , u. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS requiredfor MA 02601 5/10/10 every 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 0" 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.): BOX LEVEL NO LEAKAGE SLIGHT SCUM LAYER 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•0901 Tide 5 Official Insp ection 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 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 CULTEC ❑ 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.): DUG DOWN TO TOP OF CHAMBERS STONE IS CLEAN WITH NO SIGNS OF HYDRAULIC FAILURE Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09A8 Tits 5 Official Inspection Form:Subsurtace Sewage Deposal System•Page 13 of 17 r u. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•09N8 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 14 of 17 Ll- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•09N8 Title 5 Official Inspection Forth: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 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name inrmation is HYANNIS requiredfor MA 02601 5/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water I ® Check cellar ® Shallow wells Estimated depth to high ground water: 34 FT SEE ATTACHED PAPER feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: OFF PREVIOUS PASSED INSP REPORT DATED 7/7/04 Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•0908 i Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 CASTLEWOOD CIRCLE Property Address WHITE Owner Owner's Name information is HYANNIS required for MA 02601 5/10/10 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATIONi /71- . Si 0_C /�YC�3EWAGE # VILLAGE_ X�i iti� ASSESSOR'S MAP&L� _ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY L� n 0 (�-�y �. LEACHING FACILITY: (type) C o (size) NO.OF BEDROOMS R OR OWNER 7 Z�� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet A Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prosy Address::4 1U Cz;i 3-114✓0(9 Jj IS Odzo/ Owner. d�►'� Date oaf Inspection. 9 999TCJR 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 400 feet.Locate where public water supply enters the building. 3 �/^ a a, ) � a � a - �a _ as G3 Gy_ 31 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: -epwr Q/ Owner. r►�v✓ Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation- Obtained from system design plans on record-If checked,date of design plan reviewed T Observed site(abutting property/observation hole within 150 feet of SAS) hecked with local Board of Health-explain: iMAeS� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You m �j�cribe how you estab�}'shed the high ground water el a on: / o7y0V-7 o >� Lam-,�lr,� q., �x/OW C2 0011e, _ C ` l �J � •`:�F. '� y �' � rr is f J CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated '—cZ—Qj G , concerning the property located at 1 '� o— CQ Rai w d V-d C e meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system", • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNED:'A t DATE: ' LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. JJ �j ! LADS INVESTOMO INIC., a Massachusetts corporation hiving n its usual place of business in Yarmouth (West), Barnstable t:oumy, Mass- achusetts, owner of Lot No. 3, shown or. Land Court Plan No.2e349B, (Sheet j 1), under Certificate of Title No. 32871, hereinafter called the GRANTOR; for consideration paid, grants to ALICE A. SANMERS, of _ Castlewood Circle, Barnstable (I?yannis), Barnstable County, Massachusetts, being mar:•ied, owner of Lot No. 4, shown on said Land Court Plan No. —4349B(Sheet 1), under Certificate of Title No. .38432 hereinafte; called the GRANTU; a perpetual right to tnaintailr a Septic tank and/or cess pool upon the northerly portion of /apt No. 3 as above referenced, which portion t1 ! is defined as follows:. Beginning at it point on the northerly boundary of Lot No. 3, 2T feet from. Castlewood Circle on the boundary line separating Lot Nr. '.•n� Lot No. 4; thence running i i Southerli• into said Lot No. 3, four (4)feet: thence running Northwesterly in said Lat No, 3, five (5) feet; thence r=,ing Northerlyon a line parallel with tte first mentioned bound to said boundary line ccrarating 14ts No. 3 and 4, two and 751100 (2.75) i•. feet; hence run::ing Easterly by said boundary tine of Lot No. Q. and 4, five (5) feet to the point of begi►uiino. IN \V1TNrSS WHERL•'Or, the said LADS 1NVL•'STO12S, lh'C. , has { caused its corporate seal to be hereto affixed anti these presents to he signed, ackno%v!edged and delivered in its name and boinalf by Sidikly Gluck, its Pres- ident, and Larry Gluck, its Treasurer, hereto dully autborizcd timdes.\'ote recorded with the• Barnstable County llrgistry of Uceds as Bo`gnk�iq>3t �°ltte 98,995, this 10th day of December, 1 66. c j� �� •��'�'% G= 131� idnev Glu lc nt'�• :. The Commonwealth of BY: Larry Gl cl;, l'ic� k ,t,:dYcasure A4assachusetts, Barnstable, Ss., December 16, 1960 Then personally appear ad the above named Sidney Gluck and Larry Gluck and acknowledged the foregoing instrument to be the free act and deed of Lads lnvestors, Inc. bvf lee ?rotary public, My commission exyiros:April 7, 1973 •IuCG;/ 6= .._._ wn�e:earlAaL+.ASM�v+.••��+�rti.irn�'r'.a'd'�r.".:`j` ' 00 �'�' _�.ui�sd:w::.t•vNN'h'in'VW:aa�t.':�.r:i.• ��r-• ... ..s �' —. .. Fes! • �� vJ. .v�." I. .moo .• .. �. .• .mow .. . ���� )+nwKnnnar f,9T.bf,G/f309i bE:EZ 1700ZIL0/L0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of compliance THIS 1S TO V that_Won Sew a Disposal System-installed X by'. F20AWon S4 p Y , ( )or repaired/replaced( )on for Alice Sanders as Casitlewood Circle annis with the provisions of Title 5 and the for Disposal System Construction Permit No. has been constructed in.accordance Use:.of'this system is conditioned.on compliance.with:the provisions set forth below: dated Fee 40.00 THE COMMONWEALTH.OPMASSACHUSETTS PUBLIC HEALTH.DIVISI.ON.- BARNSTABLE, MASSACHUSETTS Ig lOgaY pgtem Ottg.truction erlTtit. . Permission is hereby granted to W.E. Robinson Se tic Sere . to constrict( )repair(X )'an On-site Sewage System located at 172 Castlewood C rCle Hyannis , and as described:in the above Application.for Disposal.System Construction Permit.The applicant recognizes his/her duty to comply with Title 5-and the following local provisions or special.conditions. All constructionariust be completed within two years of the date below. Date: Approved b4EL , r ' Y- .I. • J Iicgistrred and Unregistered Barlisi;jbic, ss. LADS IN71TSTORS, INC.. TO ALICE'A. SAM)MIS I'11RPf:TI'A L 111014T Kc\;k%VEG CA AkG5oAATWN t uLmc,.aarn,ir.0 w„9 ►'J/...� ✓1 wcJi+Llx�twY+pLo{.=Si:rMl.d.:� 1 t •5 i ! CHARLES 1. ARDITO ATTORKY AT UW T:nT•Tu•O Huior►o 9unclaio Wm TWWOY14.NAUACHvirm7 01671 bo RA/fA 3Jtid L!ONNODOJr 69ib6SL80ST bE:EZ 170OZIL0/LO I ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a s 'y✓I� 9 03 � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 4� • �� Od 6 0/ Owner's Name: t` ci ri ?r Owner's Address: 7,2 G�. a woo Ci.r� R ECEIVED Vine Od 40/ Date of Inspection: /� Name of Inspector, lease print)�ar� /'o l e ll 'Company Name: �A1V# 0 — Mailing Address: O.X of 8� Telephone Number-so T_T 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: t— Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Gar Date: /o Q T'he system inspector shall submit a copy of this inspection report to the Approving Authority 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 se to the system owner and pies sent to the buyer,if applicable,and the approving authority. con i Ji o v, �� !'01 .N 9.rfPS ,�jG�C�► N r"e /Q v�l,� ne e c�l O�J Ale, Notes and Comments ,SC d G %a a l r n e ,(j� T4e 7/2/Oyl `las h o/r ToIM IOA-4*1 wi Y-4t �avns7�s6/� Cg���ov�� a• ,Vi 14, , �asroeh4 a-flt►ctied RePo��, ****This report only describes conditions at the p �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: 1 nn C� �( rf✓oo � Gt✓' Owner_ ",CV 'il of Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System.Passes:. _Z 1 have not found any information which indicates that any of the failure criteria described 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. in 310 CMR Comments: B• SY Conditionally.Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass Answer yes,no or not determined(Y N,ND)in the for the following statements.If"not determined'please explain The septic.tank is metal and over 20.years old*or the septic tank(whether metal or not)is structurally unsound;exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank-is replaced.with a complying septic tank'as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND.explain:. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or-replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s)_The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed �1 ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A l . CERTIFICATION(continued) CProperty Address: / �d`- G"*Wo o C! Cie-* I �.,Gr�nil./yl O0L(001 Owner_ Date of Inspection: Q C.(Further Evaluation.is.Required.by.the Board of Health: IL/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 accordancewith 310 CMR 1&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.withm 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..frnmpollution 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6�- J-*Ivvod 6/✓' c —�hhIf . /yl9 O�60/ Owner: --e4vr r Date of Inspection: o 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 logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or d1 � epth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number iof 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. rtion of a cesspool or privy is within a Zone 1 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. (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.] /0(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large 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) s 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. Page 5 of t t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 1/ CHECKLIST Property Address: �� (-( Cvc �f H Gnh' a60/ Ow Her. N Date of Inspectiew q Q Check if the following have been done.You must indicate`yes"or-no"as to each of the following- YesAo ✓✓ prng information was provided by the owner,occupant,or Board of Health — — Were.any:of the system,components pumped out.in the previous two weeks — -boe system received normal news m the previous two week period 1 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 cnspec.'ted for signs of sewage back up as the site inspected for signs of break out — — ere all system components,excluding the SAS,located on site _ Were the septic lank manholes uncovered;opened,and the interior of the tank inspected for the condition ofthe taffies or tees,material of won;eons;depth of liquid,depth of sludge and depth of scum Z--f Was the facility owner(and:occupants if different-hurn owner).provided with.information on the r marntenaace,of subsurface se Pre1� wage 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- De _ _ termined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CNM 15.302(3)(b)] I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property.Address: / 65 / l wood cc v- Gnnrf ,/LJ�g OotGo/ Owner. ar Date of Inspection: 6 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms-(actual): DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): Number of current residents: - O Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):� [if yes separate inspection required] Laundry system inspected(yes orno):A Seasonal use:.(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203)- End- Basis of design flow(seats/persons/sgft,etc.). Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION ' Pumping Records f Source of information /C/o 0 N,-V e / ? (k�,f — p Was system pumped as part of the.inspection(yes or no):" . If yes,volume pumped—__Sallons—How was quantity pumped.determined.? Reason for pumping: TYP SYSTEM eptic tank,distnbution box,soil absorption system _Single cesspool _Overflow cesspool nivy Shared"system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach.a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: TG�lr o ti, s l e S•.9 S � Were sewage odors detected when arriving at the site(yes or no): At,/ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM/INI�'O/RMATION(continued) Property Address: l�a CJ l /W,9oIf C Owner. r► w t/ Date of bapectiun: &9A DUII.DING SEWER(locate site plan) �/t P�Y✓Q� v" -e Depth below . To,, 4. do� Materials of construction: cyst buon _40 PVC_other(explain): Distance from private watts supply well or suction line: Comments(oar condition of joints;venting,evidence of leakage,etc.): - SEPTIC TANK.zoo:te on site plan) Depth below grade: Material of construction�Xoncrete—metal fiberglass—polyethylene —other(evlain)If tankis metal fist age: 1s age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) / Dimensions:. ,j X 7Gy1 Sludge depth / Distance-from top of sludge to bottom of outlet tee or baffle:.. Scum thickness:' ` •• - to s s Distance fromtop:ofscum to opof Distance from bottom of scum to f outlet tee or baffle: 8 How were dimensions determined• �v/G Rct S algwl�e . Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as�to ou)let invert,evidence of leakage,etc.): / J G , T !✓ 1, g 0o c' 614 o� 7�o v� . GREASE TRAP&- O�ocate on site plan) Depth below grade:— Material of construction:—concrete_metal_fiberglass_polyethylene—other (exp ): 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 baffie 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.): Page 8-'of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM SY STEM/ INFORMATION(continued) Property.Address• /oC. 6 Ie ft/oo d C!r 11 H I pro Owner. N d' Date of Inspection: 0 TIGHT or HOLDING TANK:��tank must be pumped at time of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions; Capacity: eallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date oflast pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: if present must be opened)(locaie on site plan) Depth of liquid level above outlet invert L/IQ/✓"!a [. Comments(note ifbox is ievel'and distribution to outlets equal,any evidence of solids carryover,any evidence of into or out of bo etc.): o e&'.��- o So/I Cs So / f Q I.; .X e, !C e- �iT y�- 41-11 I _FA If. �NI h C L.i C W S16-> /V/SjI rl5 %2$ PUMP CRAMBER.4--'(locate on_site plan) ✓ ' Primps 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION(continued) Property Address: / /G� Cyr I /yl 00"01 Owner. �a� ¢r Date of Inspection: 0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ln/_ bl 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.): {�40 Gwcj Sol / C �pa v, Gwci d✓ /�/'J p v y ia�.. ,G time• CESSPOOLS:N (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: (locale on site plan) Materials of construction: Dimensions: Depth of solids: Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ownec. saw Date of Inspection SKtTCB 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 400 feet.Locate where public water supply enters the Building. 3 yr �: dr a a o G y _ 31 f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / ) SYSTEM INFORMATION(continued) Property Address: 1 �o� �GJ TI(voo d c/ CP-C-0/ Owner:-!�--,'do v Date of Inspection: 7 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed 9}s;erved site(abutting property/observation hole within 150 feet of SAS) Necked with local Board of Health-explain: !M�►�S T� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You m cnbe how you estab 'shed the high ground water el ati / ,757, A /9 j If G iO H✓� r. f Zotie, _ C TvP o f- (�.•d�� ( ' ► �< <�` .� Yam, �- r.r d )-d Je1151�iA7�,v%,7 I I ' CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) , hereby certify that the application for disposal works construction permit signed by me dated —cZ—Qj , concerning the property located at dot C Q'e/E &u d meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system\ • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED. J, DATE: _ � LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r �. ....r.i ....Y.. .. l t LADS INVESTORS, INC., a Massachusetts corporation having its usual place of business in Yarmouth (West), Barnstable t:ou=y, ass- E achusetts, owner of Got No. 3, shown or. Land Court Plan No.24349B, (Sheet i 1), under Certificate of Title No, 32871, hereinafter called the GR9NTOR; for consideration paid, grants to ALICE A. SANDERS. of Castlewood Cir clu, Barnstable (I?yannis), Barnstable County, Massachusetts, being married, owner of Ut No. 4, shown on said Land Court Plan No. I :� -4349B(Shce't 1), under Certificate of Title No. '38432 hereinafter called the GRANTIM i a perpetual right to tnaintaitt a septic tank and/or cess pool upon the northerly portion of Lot Vo. 3 as above referenced, which portion 8 i is defined as follows: Beginning at it point on the northerly boat-idary of Let No. 3, 7' feet from. Castletood Circle on die boundary line separating Lot Nr. r.•n�. .� Lot No. 4; thence running i ScutherLy into said Lot No. 3, four (4) feet: thence running' Northwesterly in said Lot No. 3, five (5) feet: thence (•:(((tang Northet•lyona line parallelwtth Ole first mentioned bound to said boundary line ccraratirg Lots No. 3 and 4, two and 75/10 (2.75) i feet; Offence running Easterly by said boundary live of Lot No. 3 and 4, five (3) foe: to the point of begitmin;. IN NuI'I ss LS'HirYiL•:oi-, the said LADS INVL•'STORS, INC. , has caused its corporate seal to be hereto affixed awl these presents to tie signed, acknowledged and delivered in its name and behalf by Sidiuly Cluck, its Pres- (dent, and Larry Gluck, its `l'rcasurer, hereto duty authorized amdes-Fete irecorded widt the Barnstable County Rrgistry of Uceds as QJ.• ..� .• '.mod��� 98,995, this 16th day of December, 1 66. f,4 •- �' LAr it� kt T RS, ► to - S a Gr •u dill idnev Glu )t nY�. �t •'tip '1'hc Commonwealth of 1M Larry G1 ck, 'l'ictr� acasuzr Massachusetts, Barnstable, ss., December 16, 960 Then porswtally appca •d the above (tanned Sidney Gluck and Larry Gluck and acknowledged the foregoing instrument to be the free act and deed of Lads Investors, Ync. )xf Ilee Rotary public, 141,y commission oxpiros:April 7, 1973 4'sm3nCrvaAtr�A•ih►a4e'•Mu'.�Y� �•' '- 000 MAU �MS.f vVvv N/N'7ri'O'PP:000t'..�•`.�• t v.. FA/7.G1 '30tid L'ONNOOO-If 69106SL8091: bE:EZ b00Z/L0/L0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS ►�'� .� Certificate of. Compliance THIS I. T.. th t. a On-site sew a Disposal System'installed X by': W.E.' Fto�j nson Sep c ( )or repaired/replaced( )on as 1 Cas.tlewood Circle for Alice Sanders anrtiS has been constructed in.accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Use::of'this system is conditioned on compliance with:the provisions set forth below: dated �� No. Fee40.'00 THE COMMONWEALTH.OF, MASSACHUSETTS PUBLIC HEALTH.DIVISION.=:BARNSTAB.LE, MASSACHUSETTS fg ogaC pgfent Conkruwttion hermit. . Permission-is hereby granted to W.E, Robinson Se tic Sery to construct( )repair(X )an On-site Sewage System located at 172 Castlewood C rcle Hyannis and as described:in the above Application._for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title Sand the following local provisions or special.condifions. • All constructionmust be completed within two years of the date below: Date: �---�� Approved b . r Registered and Unregistered i3arnst�blc, ss. � Q • � L.4pS 11\'1'1:STOR5, iT,C.. TO ALICJ?A. SANMERS `3 P1?R PPTV A L 111014T Ke��VEG•CF elfnDidATWp 0 AL.7/.. , � - r�Ji+'1,u1MaMbolr—Swl+wl.h..� . Esc G;,.,. Lnl a Y v 3 v CHARLES J. ARDJTO ATTORND AT Uw T'lTTY•TY'7 tiU1.31tLD BUIw^INC . . - Wm TAAM64TII.34MACKm T7 016,7 s EG1/F0 Cd L!ONNOOOJf G91069LBOST b£:£Z b00Z/L0/LO ,.��-� �--._�,. .'.'..`..�...�..- -�..--._-_.-_ v -... .-�. -.....ice .r,`..._ ..� �� . .. ..� .... •.`.t .'.. .. .- ...� -. .... -.- -. f .-�y- No. 3, q,2 _ Fee J_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for Migpogal *pgtem Construction Vermit Application for a Permit to Construct( . )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 C Owner's Name,Address and Tel.No. I t4anrl Al I cz A. Son&Q r6I Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 7 '3 3� Designer's Name,Address and Tel.No. i 1GDY1 l�2S Son Lf C , Type of Building: Dwelling No.of Bedrooms..=s Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T_01-3r6l l --ih i t. d,j 9n ny4J o� 15exA_/c -tank Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue msoard a alth. Signed J0 Date 7 l/ Application Approved by Date Application Disapproved f r the ollowing reasons ' Permit No. o Date Issued 9 No. `J/ . at. Fee .—AZ THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIppricatton for �Diopaar *potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System E)Individual Components Location Address or Lot No. ]s Ow er'$Name,�adress and Tel No. NI�I I CZ A. jdk Y/L"d�ilX S Assessor's Map/Parcel OC, Installer`s Name,Address,- d Tel.N_o� 1 Designer's Name,Address and Tel.No. x ' Type of Building: Dwelling No.of Bedrooms _S' Lot Size sq.ft. Garbage Grinder( ). Other Type of Building No.of Persons Showers( ) Cafeteria( ) • Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) e�rja1I taxjj 4u, 911 oup Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance-has been issu Y-t is. oaarr�d-of ealth. / / /^� `Signed (I C' �� Date /C / Application Approved Z177,114 e g �te Date Application Disapproved for the following.reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS phl� BARNSTABLE, MASSACHUSETTS 5 Certificate of (Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( ) y S,I"' 111QCA m6e and Son zor— ' at 17 : Clci571 E.W vo Cax WD 11 S V ((Aas structed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ai d Installer Designer n The issuance o—f7f his p rmit shall not be construed as a guarantee that the ste ilOfunctio esigP d. — Date /1) a id Inspector ��1 � �� Fee z_ No. — --------------------- THE COMMONWEALTH OF MASSACHUSETTS �j PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS i 0 aY gtem Congtructlon Permit � g� g �p Permission is hereby, ranted to C nstruct( )Repair( )�upgrade( )Aba don( ) System located at 1I� C-a5newood C,c r" ' H11w i 5 i r�L.•o, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons cti, e co ,pleted within three years of the date of this Date:_ /1 Approved by - A&SESSORS MAP NO; No. i ���� PARCELN� •1 Fee 40 .00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migozal *pgtem Con!5truction permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 172 Castlewood Circle Alice Sanders Hyannis Installer's Name,Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No. W.E. Robinson Septic P.O. Box 1089 Centerville Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder(n9 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil gravel Na of a airsor Alterations(Answek&henWlicabl ) install 3 high capcity infiltrators C� �S ve P — 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 Cod and not to place the system in operation until a Certifi- cate of Compliance has been issued.by this Bo oLklealth. _ p, Signed Date Application Approved by Application Disapproved for the following reasons Permit No. l ll Date Issued No. / a ,1? ' / Fee 4 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF*BARNSTABLE., MASSACHUSETTS— application for Dtgpool *paem Comaructton Vermtt Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name;Address and Tel.No. 172 Castlewood Circle Alice Sanders ; Hyannis Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W.E. Robinson Septic i P.O. Box 1089 Centerville Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder(n9 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per.day. Calculated daily flow gallons. gPlan Date Number of sheets Revision Da e — .j i Title w Description of Soil gravel Natt3y�,of a airs or Alterations(Answeb,when aplicabl ) install 3 high capcity infiltrators Date last inspected: Agreement: Al The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system � in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo awl o ealth. p, Signed Date j Application Approved by Application Disapproved for the following reasons Permit No. DaAl ssued i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS r Certtftcate of Comphance - THIS IS TO CERTTI'Y th t the On-site Sew a a Disposal System installed( )or repaired/replaced(x )on b W.E. Robinson Septgc for Alice Sanders y as 72 Castlewood Circle Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. w dated ;V, Use of this system is conditioned on compliance with the provisions set forth below: No. % Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS M.5poal *pgtem Comgtructton Vermtt Permission is hereby granted to W.E. Robinson Septic Sery to construct( )repair(x )an On-site Sewage System located at 172 Castlewood Circle Hyannis and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. 1 Date: '� Approved b,4, I I CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated Z,-/--P —cj , concerning the property located at 1 '� C a f/i w a-0-� /�� meets all of the s A Oa - following criteria: IVIO- • There are no wetlands within 300 feet of the proposed septic system, • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i , - SIGNED:A � ( DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r l\ O J1 " r t rrr �� 0 TOWN OF BARNSTABLE LOCATION 17Z ST�� *a'G 4-C /1PC 4/SEWAGE # Zt"' // VILLAGE ASSESSOR'S MAP& dlT-- 1 -- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:,(type) . T (size) .rY A," c:? 3 NO.OF BEDROOMS R OR OWNER A.Z,,e � PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table,and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge,of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by P o o � o 1 Y y } .1 � � i