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Home My WebLink About0342 CASTLEWOOD CIRCLE - Health 342 CASTLEWOOD CIRCLE,HYANNIS A=273.035 e r f i ew a 7g-OL5,6, Commonwealth of Massachusetts \"� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z 342 Castewood circle Property Address t.d. Razinha Owner Owner's Name O? information is a required for every Hyannis Ma 9/9/16 page. City/Town State Zip Code Date of Inspection {3} 4% ra'1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name-of Inspector key. H.P.S. ,� Company Name P.O.Box151 Company Address Forestdale Ma 02644 Cityrrown State Zip Code 774-274-2581 12866 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 16.340 of Title 5(310 CMR 15:000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/9/16 spectol nature Date The system inspector sh ubmit a c y of this inspection report to the Approving Authority(Board of Health or DEP)with' 30 days o ompleting this inspection. If the system is a shared system or has a design flow of 1 0 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 ad copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owners Name information is Hyannis Ma 9/9/16 required for every y 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: { existing system meets title regulations. system is in good operating condition at time of inspection 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): I `t5ins-3113 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every — page. CitylTown State zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 J 4r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 page. City/Town 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: existing 1000 gallon septic tank is 1 foot off the bulkhead of house. House has a full foundation that is poured concrete. there is no indication tank is leaking and saw no visable cracks. tank has concrete baffles in place. Owner of house had installed risers on ilet and outlet of tank. origanal report was summited to Health dept as a needs further evaluation by local Approving authority. Health department inspectors deamed tank could be left in its current location and system is a passing system. 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 0 ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owner's Name information is H annis Ma 9/9/16 required for every y page. Citylrown 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. t5ins 3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u . Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM s.a' 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No 0 ❑ 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) Z ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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•3/13 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 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma' 9/9/16 y page. Cityfrown 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: owner 3 years 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): t5ins-3/13 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 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: tank unknown leaching updated in 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 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.): Septic Tank(locate on site plan): Depth below grade: 1.2' feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) tank is 1000 gal H10 tank is in good condition no visable cracks or leaks. tank is located 1 foot off bulkhead of house 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: 31. t5ins•3/13 Title 5 Official Inspection Farm: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 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma. 9/9/16 page. Cityfrown 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 31" 2" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 20" 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.): pump every 2-3 years as maint. to protect leaching Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts �'� ��.•�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not..ibr voluntary Assessments M 342 Castewood circle Property Address RazinhaY' Owner Owner's Name 'a information is ` . required for every Hyannis Mai 9/9/16 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 ofleakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: 41 ❑concrete ❑ metal ❑ fibel7glass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day r Alarm present: ❑ Yes ❑ No ,y- Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: r. Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Citylrown State Zip Code Date of Inspection A -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.): no Dbox 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.): a *-If pumps or alarms are not-in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: flow defusers were located and dug up a inspection port was installed. infultrators were dry at time of inspection t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 81' infultraultrators ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system � I Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 page. City/town State Zip Code Date of Inspection D. -System -Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every page. Citylrown 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 0 p � A I- 2� t5ins•3/13 Title 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 w 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y 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: 18'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: Town GIS maps lot is el.68 You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w -342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 page. CityrFown 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: 18 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: Town GIS maps lot is el.68 You must describe how you established the high ground water elevation: k • Y Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Pa'ge•16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Cityfrown State Zip Code Date of Inspection S 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OP_- SANDWICH LOCATION: VILLAGE: LOT # : PERMIT INSTALLER' S NAME: INSTALLER' S PHONE # : ;yL LEACHING FACILITY: (type) L' NO. OF BEDROOMS : Z_ BUILDER OR OWNER: LU ✓v'tT�,i`u PERMIT DATE: COMPLIANCE DATE: f -dam- DRAW DIAGRAM ON BACK J TOWN OF 9AI I LOCATION: j, J,,, VILLAGE: ir ✓/2/YI/l/1 , LOT # : PERMIT INSTALLER' S NAME: J 4' INSTALLER' S PHONE LEACHING FACILITY: (type) 2A�26 y�S NO. OF BEDROOMS .�.. BUILDER OR OWNER: ti✓t PERMIT DATE: COMPLIANCE DATE a DRAW DIAGRAM ON BACK � � j- y n r �' �� '. �� Q NtP �i � �� :. i r. ` i a f'v �. 1.. �� . __ r,, E t , t � No. e! A Fee�V t •'- THE COMMONWEALTH-OKMASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS i 0(ppl cation for �Digpool *raem Construction Permit Application for a Permiv'to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 G,35 Owner's Name,Address and Tel.No. 3q�Z4e, - c t Assessor'sMap/Parcel Inst a �ddressrand Tel.No A".. Designer's Name,Address and Tel.No. cry Type of Building: Dwelling No.of Bedrooms :2 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 Rgpairs or Alterations(Answer when applicable) ^T $X 41d C - S 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 f 'tle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu dJI&_ t 's Bo o ealth.SignedDate Application Approved by 044., Date E—-7 Application Disapproved for the to 'ng reasons Permit No. 9 Date Issued No. „ Fee =` THE COMMONWEALH" 'F`-MASSACHUSETTS Entered in computer: Yv ✓ -PUBLIC'HEALTH DIVISIOW-TOWN OF BARNSTABLES MASSACHUSETTS 01�1.prication for Migpogat *pgtem Congtruction Permit Application for a Permit o Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. .3 b-3 5 Owner's Name,Address and Tel.No. Assessor's Map/Parcel ki( M Inst Address,.and Tel.No. Designer's Name,Address and Tel.No. w� Type of Building: Dwelling No.of Bedrooms 2'— 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 WRpwirs or Alterations(Answer when applicable) 7— .S>C 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 f 'tle 5 of the Environmental Code and not to place the system' in operation until a Certifi= cate of Compliance has been issu b t 's Boar o=ealth. - Signed Date � 2` p Application Approved by Date l - - Application Disapproved for the owing reasons Permit No. q 51 - a(a Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(k)Upgraded( ) Abandoned( )b at 3 y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - U dated Installer Pin.• Designer The issuance of is pe t shall not be construed as a guarantee that the systemM fun -on-as esigned. 1 Date �` `�J Inspector �c�.t� t --------------------------------------- No. b Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon System located at ,3 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: lip / Approved by 1 1/6/99 NOTICE: This Form Is To Be, Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works con truction permit signed by me dated f 7— �� , concerning the property located at S'��- 64 meets all of the following criteria: • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) G; 7 B) Groundwater Table Elevation max. adjusted g.w. _ DIFFERENCE SIGNED : DATE: [Sketch proposed pl of system on back]. q:health folder:cent 9" V THY l_ O ® � 7 � A 4 Commonwealth of Massachusetts J,7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments CAI M 342 Castewood circle Property Address t-+ 4h Razinha Owner Owner's Name {�} information is required for every Hyannis Ma 9/9/16 page. Cityrrown State Zip Code Date of Inspection tp 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 Chad Hathaway use the return Name of Inspector key. H.P.S. �y Company Name P.O.Box 151 Company Address few Forestdale Ma 02644 Cityrrown State Zip Code 774-274-2581 12866 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: qbs/�` ❑ Passes ❑ Conditionally Passes ❑ Fails 411 i f Cr�eric, #"' D ftw�t i!!a?1 �q,►.erw� ® Needs Further Evaluation by the Local Approving Authority A �j /�A idt-Pa^d^4'v, andt-A Ail ten I`k'A J Q r'o or -� / !Q 7 d 7. 9/9/16 ?'JM of IA*Ll ,10-4 Inspector's Sig re Date The system inspector shall sub a copy o this inspection report to the Approving Authority(Board of Health or DEP)within 30 ys of completing this inspection. If the system is a shared system or has a design flow of 1 0,00 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every Y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): r ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ® Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. 1 Method used to determine distance: S **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: existing 1000 gallon septic tank is 1 foot off the bulkhead of house. House has a full foundation that is poured concrete. there is no indication tank is leaking and saw no visable cracks. tank has concrete baffles in place. Owner of house had installed risers on ilet and outlet of tank. i, Y D) System Failure Criteria Applicable to All Systems: a You must indicate"Yes"or"No"to each of the following for all inspections: Yes No 0 ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is H annis Ma 9/9/16 required for every y page. Cityrrown 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 El ❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑• Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 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-3/13 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 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. CityfTown 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: owner 3 years 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): t5ins•3/13 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 M 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 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: tank unknown leaching updated in 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'8 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.): Septic Tank(locate on site plan): Depth below grade: 1.2' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) tank is 1000 gal H10 tank is in good condition no visable cracks or leaks. tank is located 1 foot off bulkhead of house 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: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y 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 31" 21' Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 20" 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.): pump every 2-3 years as maint. to protect leaching Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 342 Castlewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. City(rown 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.): no Dbox Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: flow defusers were located and dug up a inspection port was installed. infultrators were dry at time of inspection t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ Teaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 8'x40'x1' infultrators ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is Hyannis Ma 9/9/16 required for every y 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 page. Citylrown 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 k LT I' 1 J � I - ' _ 301 t5ins-3(13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 18 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: Town GIS maps lot is el.68 You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 Castewood circle Property Address Razinha Owner Owner's Name information is required for every Hyannis Ma 9/9/16 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 AsBuilt Page 1 of 1 TOWN OF SANDWICH LOCATION: j VILLAGE: t�rtil�l LOT #: PERMIT #: INSTALLER'S NAME: INSTALLER'S PHONE #: :4, 2 zt e> LEACHING FACILITY: (type) NO. OF BEDROOMS: Z, BUILDER OR OWNER: W PERMIT_DATE• Z- ^- r COMPLIANCE DATE: 9 / DRAW DIAGRAM ON BACK ' t a c, i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=273035&seq=l 9/15/2016