HomeMy WebLinkAbout0021 REGATTA DRIVE - Health 21 REGATTA DRIVE, HYANNIS
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s MCINTYRE, CAROL D &ALFRED S TRS
rL-n1 Seni21 REGATTA DR
C3 CENTERVILLE, MA 02632
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'MCINTYRE, CAROL D &ALFRED S TRS
�121 REGATTA DR
:CENTERVILLE, MA 02632
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PS Form 3811,July 2015 PSN 7530-02-000-9053 omeU stic Return Receipt
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Postal Service
T.own:of Barnstable
O` "61th Division
Main Street
` `--,annis,MA 02601
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Commonwealth of Massachusetts
: p Title 5 Official Inspection Forms
Subsurface Sewage Disposal System Form- Not for Voluntary Assessmentsk
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Na z'
information is
e n I S r .1
required For every MA 02632 11-28-17
page. CityrTown V State Zip Code Date of Inspection -
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information p
filling out forms S� /C2 3-60- ���pluuurupi
use onl on the oche tab 0 OFsS''��,
y 1. Inspector:
key to move your `per:'•
cursor-do not James D.Sears JA MES N
use the return _ 9: R
key. Name of Inspector SEA �
QCa wide Enterprises
Company Name
153 Commercial Street ''��F S INSPIL 0I E�' �``��`
Company Address
rwm Mashpee MA 02649
Citylrown State Zip Code
508-477-8877 S 1623
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
1-10-18
spector's Signature Date a
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 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.
Mns.doc-rev.8r15 Tula 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of V
z°� VIS
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i
Commonwealth of Massachusetts
kp Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
tion isrequirredfore very Centerville
MA 02632 11-28-17
page, CftylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E J 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:
The system is a 1000 Gal.Tank D Box and pit Note: Revised report Disposal removed 12 18 17
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):
t5lns.doc•rev.6116 Title 5 Official hsperWrl Forth:SLbsurreca Sewage Disposal System•Paae 2 of 17
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Commonwealth of Massachusetts
_ a Title 5 Official Inspection Form
i, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information s Centerville MA 02632 11-28-17
required for every
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):
❑ 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
l6ins.doc-rev.6/16 Tilts 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 3 of 17
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Commonwealth of Massachusetts
UU Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information i5 Centerville
required for eve MA 02632 11-28-17
page. CityrTown State Zip Code Date of Inspection
B. Certification (cunt.)
2, System will fall unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in MiRn is less than 6" below invert or available volume is less
than '/dayflow 151'T
t5ins.6oc-rev.611 s Title 5 Official Inspection Form:Subsurface Sewage Disposat System-Page 4 of 17
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c `>� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
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 16,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes' in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6116 Title 5 Ofdal Inspecdon Form:Subsurface Sewage Disposal System•Page 5 of 17
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I
c `•� Commonwealth of Massachusetts
Title 5 Official Inspection Form
ti Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�! 21 Regatta Drive
Property Address
McIntyre Trust
Owner Owners Name
information is
required for every Centerville MA 02632 11-28-17
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
❑ ® 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of 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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6l16 TIMs 5 Official InspWion Form:Subsurfaoe Sewage Disposal System-Page 6 of 17
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f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
Information is required for every Centerville MA 02632 11-28-17
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
1000 Gal. Tank D Box and pit.
Number of current residents: 0
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)): NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
CommerclaVindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(sad)
Basis of design flow(seats/personslsq.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.0oc•rev.6/16 Tits 5 Official Inspeclan Form:Subsurface Sewage Disposal System-Page 7 of 17
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
1,
21 Regatta Drive
.1 . Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town 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: NA
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):
t5iris.doc•rev.6/16 Tilla 5 Official Inspeclion Farm:Subsurface Sewage Disposal System•Page 8 0117
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
C `, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town State Zip Cade Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
1995- Permit#95- 630.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20
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.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade:
10"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
1
Sludge depth:
t5 ns.doc•rev.6116 Tille 5 Official Inspection Form:Subsurface sewage Disposal System•Page 9 of 17
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Commonwealth of Massachusetts
vvw Tithe 5Officia Official Form
SewageSusuace p y Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness
0"
8
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? Asbuilt-Tape
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.):
Tank at working level. Tank and covers at 10"below grade. In and outlet tee's. no sign of leakage
or over loading.
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: pate
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage oisposai System-Page 10 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
k Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
21 Regatta Drive
Property Address
Mclntyre Trust ----
Owner Owner's Name
information is Centerville MA 02632 11-28-17
required for 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 ❑ 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.doc•rev.6115 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town 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.):
D Box is 16"x16"-20" below grade w/one line out. Box is clean and solid.W/no sign of over loading
or solid carry over.
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 krated, explain why:
Nns.doc•rev.6/16 Title 5 Official Inspection form:Subsudace Sewage Disposal System Page 12 of 17
Zl abed xej dH L�:56 8602 06 Uer
Commonwealth of Massachusetts
Title 5 Official Inspection ion Form
'Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
Mclnt re Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc,):
Leaching is a 1000 Gal. precast pit w/2' stone. Pit at 2'below grade w/cover at 10", Wet bottom
w/clean like new wall's. Stain line at around 1'. No sign of over loading or solid carry over.
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
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£1, abed xed dH 8t,:9 6 2I.0Z 0 6 Uer
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b` Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is Centerville MA 02632 11-28-17
required for every
page Cfty/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.):
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t7 6 abed xed dH W9 6 8 60Z 01, Uef
Commonwealth of Massachusetts
Title 5 official Inspection Form
` Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
y.J 21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City
/Town State Zip Code Date of Inspedion
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
P CAR
13
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ISO
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ISWISAOC•reV.6115 Title 5 Oftal Inspection Form:Subsurface Sewage Disposes System•Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
-Y
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is
required for every Centerville MA 02632 11-28-17
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N�
Estimated depth to high ground water: Net
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: 2-7-95
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:
T.H.on Design plan 2-7-95 20'+ no G.W.. Bottom of pit at 8' below grade. Bottom of pit at 12'+
above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
9 t a6ed xed dH W9 6 8 60Z 0 6 Uef
ct\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
sl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.cloc•rev.6h6 Title b Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
abed xed dH 6b:9 6 21,02 01, Uer
Town of Barnstable Barn
A TT
ti P Regulatory Services Department A AFAmericaCity
intzrts'rnsM
y MA93.
Q i634. �,g Public Health Division
'fD 2007
""�� 200 Main Street, Hyannis MA 02601
i
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
1
CERTIFIED MAIL#7015 1730 0001 4987 6667
December 29, 2017
I
MCINTYRE, CAROL D & ALFRED S TRS
21 REGATTA DR
CENTERVILLE,MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 21 Regatta Drive, Hyannis,MA was inspected on
11/28/2017 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Must remove garbage grinder disposal or upgrade septic system.
fki. .
E „
You are ordered to repair or replace the septic system within two ( )years from the date
you receive this notification.
within the deadline period will result in future
. Failure to repair/replace the septic system w p �
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\21 Regatta Drive Hyannis.doc
rw
Health Master Detail Page 1 of 1
Lrnyed In As: -I*DWI-.•,trippv Health Master retail Friday,May 21 2019
Apolicatior Center Parc:�l i...r.;kup Selection:terns Reports
I Parcel Septic Perc_. —el
Parcel: 252-051-004 Location: 21 REGATTA DRIVE,Hyannis Owner: CHALUPKA,NORMAN F&MARILYN A
r. .......... ................... .......... ... ..,,.....�
Septic 1 Septic 2 New Septic .
..... . .......
i
Permit number: Permit type:I Select type Complete system: ❑
Issue date : Complete date : W
Septic tank size: Type/Size of SAS:
Installer:JSelect Installer %' Card on file: ❑
I/A service type Select servlcei v Innovative Alternative Technologye v
_-- Select IA type 0.
Variance date i Abandon complete date : I r Abandon permit number:
-111
Repair deadline date 12/29/2018 Repair notification date : 12/29/2017 Keyword.
Comments. •created for septic inspection -- Delete Septic
i _
..... _....,. . .. ....
Inspection 11/28/2017 Inspection 11/28/2017 New Inspection...
.. ...... ..... ............................. . ....
Number Inspection Date Inspector Result
12-68 11/28/2017 Sears James D. P(Pass)
K
Received Date Comments
1/18/2018 Garbage Disposal Removed 12-18 17 Delete Inspection
... .......
. ..:...
Save Septic Changes I I Return to Lookup
. _.,.,.,,. - _.m.. ,
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=252051004 5/24/2019
i
�'VIK%E Tom,
Town of Barnstable Barnstable
Regulatory Services Department j'��'ca�j
"`^. Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 6667
December 29, 2017
MCINTYRE, CAROL D & ALFRED S TRS
21 REGATTA DR
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 21 Regatta Drive, Hyannis, MA was inspected on
11/28/2017 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• Must remove garbage grinder disposal or upgrade septic system.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\21 Regatta Drive Hyannis.doc
THE ram,
Town of Barnstable
aA.R 51 -1.3 E,
Regulatory Services Department
X
Public Health Division
200 Main Street,Hyannis MA'02601
Office: 508-862-4644 Richard ScA Director
FAX 508-790-6304 Thomas A McKean,CEO
Feb 6, 2007
Rev. 5111116
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) _
An`x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground .
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE(1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis.'(This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
q Single"Cesspool
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
f n� 1
Repair deadline: �e �
Q:\SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc
z sez -os/ - oar f
Commonwealth of Massachusetts
I ozr-'` Title 5 Official Inspection Form t
Subsurface Sewage DISPOS21 System Form -Not for Voluntary Assessments '
'I i°aui
21 Regatta Drive #
Property Address
McIntyre Trust
Owner Owner's Name
information is
required for every ceaUwA41e Nua nn i s MA 02632 11-28-17 k5
page. CityrTown State Zip Code Date of Inspection `-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
fillingoutut forms A. General Information
f
on the computer, ��`��SN CF MgSs!r,,��
use only the tab 1. Inspector:
key to move your
cursor-do not James D.Sears JAMES m=
use the return Name of Inspector ;r„
key. _ *`
py Na Enterprises .o� o
Company Name 7� .�TTF�.'�;._
153 Commercial Street �� S .....
Company Address
Mashpee MA 02649
City[Town State Zip Code
508-477-8877 S1623
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
12-2-17
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspectior Form:Subsueace Sewage Disposal System•Page 1 of 17
g2 a5ed xezI dH K£Z LI.OZ 92 Oa0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
( Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
L
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. Cityfrown 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:
The system is a 1000 Gal. Tank D Box and pit.
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.doc rev.Bill Title 5 Offidel Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
9Z a6ed xed dH 01VU L60Z 9Z :20
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms 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):
Need to remove disposal.
❑ 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.doc-rev.6116 Title 5 Otkial Inspection Forth:Subsurface Sewage Disposal System-Page 3 o117
LZ a6ed xeJ dH 0b:EZ L602 9Z DaQ
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
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:
44 This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
` ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in is less than 6" below invert or available volume is less
than '/z day flow P;T
ins.doc•rev.6/15 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Lt5 7
gZ a5ed xeJ dH WEE L60Z K 080
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is Centerville MA 02632 11-28-17
required for every
per. CityrTown 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.
t
❑ ® 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 3 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-
10,0009 pd.
❑ ® 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.
t5insdoc rev.6116 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
6Z a5ed xeJ dH ZtbU LME 9Z 3-10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
E�
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town State Zip Code Date of Inspecdon
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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of 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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.SAIS Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
0£ a5ed xeJ did Zt,:U L60Z 9Z gad
Commonwealth of Massachusetts
Title 5 official Inspection Form
y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5
211 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
required for every tan is Centerville MA 02632 11-28-17
require
page. CityfTown State Zip Code Date of Inspection
D., System Information
Description:
1000 Gal. Tank D Box and pit.
Number of current residents: 0
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 ears usage d na
9 � Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NADate
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.doc•rev.6r16 Title 5 Official Inspecilon Form:Subsurface Sewage Disposal System-Page 7 of 17
6E a5ed xeA dH EbU L I.OZ 9Z )KI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11.28-17
page. CityrTown 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;
NA
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.doc-rev.W S Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page a of 17
EE abed xed dH Eb:EZ L602 9E )aa
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. Cityfrown State Zip Code Date of Inspection
D.,System Information (cost.)
Approximate age of all components,date installed (if known)and source of information:
1995- Permit#95 -630.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade; 20"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.):
Pipeing is 4"PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 10
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast H-10
Sludge depth:
t5ins.doc-rev.8116 Title 5 Mcial Inspection Form,Subsurface Sewage Disposal System-Page 9 of 17
£E a5ed xed dH bbU L 1,2 9Z D80
Commonwealth of Massachusetts
u1RTitle 5 official Inspection Form
.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owners Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0" �
Distance from top of scum to top of outlet tee or baffle 8
Distance from bottom of scum to bottom of outlet tee or baffle
is.,
How were dimensions determined? Asbuilt-TapeSludge 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.):
Tank at working level. Tank and covers at 10" below grade. to and outlet tees. No sign of leakage
or over loading.
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.doc•rev.6116 Title 5 0oiciai Inspection Form:Subsurface Sewage Disposal System•Page loot 17
;y£ a6ed xed dH t7t7:£Z LI.OZ 9Z DE10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
I
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.tloc•rev.6116 YWe 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17
qE a6ed RJ dH t,b,U L 602 9Z D80
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Regatta Drive
Property Address
_McIntyre Trust
Owner Owner's Name
information is Centerville MA 02632 11-28-17
required for every
page. Cityffown 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.):
D Box is 16"x16"-20" below grade w/one line out. Box is clean and solid.W/no sign of over loading
or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.)'.
If pumps or alarms are not in working order, system is a conditional pass,
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located,explain why:
t5ins.doc•rev.6116 Title 5 Ofllcla Inspection Form.Subsurface Sewage Disposal System•Page 12 of 17
9E abed xeJ dH ttU L60Z 9Z 0-10
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
equired foe fo is
every
r Centerville MA 02632 11-28-17
requir
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions.
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
Leaching is a 1000 Gal. precast pit w/2'stone. Pit at 2'below grade w/cover at 10".Wet bottom
w/clean like new wall's. Stain line at around 1'. No sign of over loading or solid carry over.
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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 13 of 17
L£ a5ed xe:1 dH SbU L 1,0E 92 080
Commonwealth of Massachusetts
z Title 5 official Inspection Form
,"p; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-W 21 Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. Crtyffown 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.doc-rev.WS Title 5 Official Inspection Form:Subsurface Sewage Oisposel System-Pape 14 of 11
gE a5ed xed, dH 9tU L60Z 9E OaG
c Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
IV.,1;
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
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
LAEck
13
o
p
o �
� 3. '3r7
t5ns.doc-rev.6116 Tide 5 Oifirial Inspection Porte:SubsuRace Sewage Disposal System-Page 15 of 17
6£ abed xed dH WE L60Z 9Z 0
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V
21' Regatta Drive
Property Address
McIntyre Trust
Owner Owner's Name
information is required for every Centerville MA 02632 11-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
No 20'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
2-7-95
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:
T.H.on Design plan 2-7-95 20'+ no G.W., Bottom of pit at 8' below grade. Bottom of pit at 12'+
above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 16 of W
0� abed xed dH WEE L 1•0Z 9Z MG
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Regatta Drive
. Property Address
McIntyre Trust
Owner Owner's Name
information
required for every Centerville MA 02632 11-28-17
page. cityfrown State Zip Cade Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, 8, 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
15ins.doc•rev.5r16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
�� a6ed xed dH 91VU LI.OZ 9Z M0
.,, TOWN OF BARNSTABGL�E
LOCATION4 S/ SEWAGE #
' VIL LACE ^ . ASSESSOR'S MAP & LOT
v�
INSTAL'Et'S NA PHONE NO.
' W
SEPTIC TAaY CAPA
LEACHING FACILITY; (type) 119 ga'a (size)
:NO.OF BEDPWOMS
' 6
BU LDER OR OViN;"--R- a G
PERMITDATI# �.3...:�c�i _COMPLIANCE DATE: / Z a t S
'Ilk
„Separation Distanze Betw"Yl.ihe �
r v�
Maximum Adjustcd-,'a r n�;l�tt�le and Bottom of Leaching Facility Feet
Private Water S® ;ly°.-.yl, hing Facility (If any wells exist
on site or wid1 p 200 fe4L 'I" acz`c facility) Feet
Edge of WetlandOd LeE,,o�;--u' ;1If any wetlands exist
Within 300 feet of le ;�:',,g 3:xe Y, Feet
Furnished by
I
TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
1
LEACHING FACILITY.(type) (size)
o�
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet c'
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
V"
A.
Q W
r
f
No-q.......... ..... . .... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Ali-pawl Work.6 (fouitrur#inn Vaiinit
Application is hereby made for a Permit to Construct (,-/) or Repair ( ) an Individual Sewage Disposal
System s at 4V'V� C -t. ------ --9_�,Z
-- ---- ---- •--
_.._c t - \ddrrss - or Lot No.
•......... ........... X. •-----•----------------------
-- . ...... --•............................................
ddress
a ---------------•--..-•---------................
Installer Address
Type of Building Size Lot---- ....Sq. feet_
Dwelling
—Type Building
pA --_ 3 Expansion Attic ( ) Garbage Grinder ( )
g— j,�J �f'
p`4 yp g ---.d���' No. of persons........................_.. Showers ( ) — Cafeteria ( )
Q' Other fixtures -.---d --------------------------------------- -------------- ---------------------------------------------
W Design Flow------------------------1_f_U-----------gallons per per day. Total daily flow......_3 .Q-..------------.--__-_-__--gallons.
WSeptic Tank—Liquid capa6ty-100.gallons Length_---_-__----.- Width---------------- Diameter._..._-.-._.-- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No--------.-_-------- Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing t k
Percolation Test Results Performed by.---- �------------------------- Date..a- ? -...-S-------•-------
,a� Test Pit No. --_minutes per inch Depth of Test Pit.................... Depth to ground water....PU 0E.___
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
ax ---
Description of Soil....' _ _.
-----•• - ------------------------------------------------------------------------------------------------------------------------------
-
U ---•-----------------•--------------------------------------------------------------------------------------------------------------------------•-------•--------------------------'•---...-------•-.••.
W
UNature of Repairs or Alterations—Answer when applicable............................_........................................_...._.....................
........... -••---------------------•-----------------••--•-•••--••-----------------........••••-•••---•----••••-----------_...---------.....----------•-•---• .........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia has been issue by the board of health.
Signed --------------- ---------------------------------------------------------------- .................................:.
- .y Dee ....-
Application.Approved By --------- J, v �.. r ..7------------------------------------------------------------- -------------
Application Disapproved for the following reafonf: ....._....._......._--------------------------------------------------/D�
------------- ......................................
....................... . ... _......... . .........................._... ........... -- ..
-
PermitNo. .. ...... .. � .. ..... . -------------- Issued ............. ...........................
ce
——J
Nod .. FEB...
-r--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun fur Dis.puuttl Works 6mitrurthin ramit
Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal
Sys at/.)
�(. � S��
,erg ,
CcLc
f../......""c.r!^:1.. 4-nL.C.. dress i—_.--•--•---•----or Lot No.
W n 1 �E cr _ {g q/ ddress
►-a ✓ ...............t;:.r.................................................. ............ .. .....
L J Installer Address
Type of Building Size Lot.---/....2!.... ..I....Sq. feet
Dwelling—No. of Bedrooms----------- -----------------------------ExpansionAttic ( ) Garbage Grinder ( )
04 Other—Type of Building W _�i�'^�r_ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
04 Other fixtures ------------------------•------------ -- --------------------...-----•--------- -----•---•--...........------...............
- ------------
d so 33 0 gallons.
W Design Flow.........................�-��l-......__..gallons per pe-son per day. Total daily flow_.____.____._______..__.___. ._......gal
WSeptic Tank—Liquid capacity._ UG(lgallons Length................ Width.......--------- Diameter_-.------------ Depth................
x Disposal Trench—No. .................... Vidth.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter-------------------- Depth below inlet-------............. Total leaching area..................sq.,ft.
Z Other Distribution box ( ) 'Dosing t nk ( ) _
-Percolation Test Results Performed by......:.�.�,�.........:�.....- .._. ��-- ...._...-__. Date........................................
as Test Pit No. 1.. _ ...minutes per inch Depth of Test Pit.................... Depth to ground water....!-�U �K
44 Test Pit No. 2................minutes per inch Depth of Test Pit.------------..-.--- Depth to ground water........................
P4 /I.....................
�' .......••------------•--•-------------........------••.........................................................
Description of Soil..--. ...Z .
x l .:
UW ........................................................................................................................................................................................................
Nature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the-State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed .... -:_.. ---------------------------------
Date
Application,Approved BY ---------- .......:-•.. a...>.av_. ...... .................... ..3--!!__ --'ter`,
. -- "�-�-----...------------`--.................... Date
Application Disapproved for the following reasons- ----------------- -------------------------------------------------------------------------------------------------,--------
-------------------- --------- ---... -- �-- _...... - _..............
........... �� - .....
/ J Date
Permit No. ' ..-''f ......7!. ............... Issued .. 1.- .-J----------
.................
J Dare
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ger#ifira e of Compliance
THIS. ,0 CERTIFY, That th ndividual Sewage Disposal System constructed ( t`) or Repaired ( )
Y L � ,b ------.V _.�„Y . .......... .... �Qe d'---------_--------------------- -_.....----...._.........----------------------------------------------------------------------
�/ In r Iler
at -------------- ---- ------� ....... .. 1! J l- ( i''`,t - - .... ..... -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .. . .. .. ""/ ------.---......................._...._.
PP � � P �,,r;... -.f�'_�:.�� dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT Be CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------------------------------..-------------------------......------. ----------- Inspector ---------------------.................... ------------------.............................
THE COMMONWEALTH OF MASSACHUSETTS
//rl BOARD OF HEALTH
N '`
''"• TOWN OF BARNSTABLE
o..� FEE....���..
1....... 9 Rapmul urku Tunutrurtiun f rrmit
Permission is,hereby granted-----
= '......_.. - ............ ..2 ".• '--............................................................
to Construct ( V) or Repair ( an I ,dividual Sewagee Disposal System
at No..... 5-9-----�J� �� �'----��a'L'c.-•----j-!! 1-i----�-'-'`/ ,�../ .. '?. - ............................................
Street
as shown on the application for Disposal Works Construction Permit Nod,f!--.-I;-------- Dated..........................................
.............................y....................._.............-------
.--------------
.........
........
..
F Board'of Health r
DATE.............................................................. ----------•-•--••
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
_ ----
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DISPo�g! PIT l faoo G� , SMi'L
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NOT' �'3A� pN �N I�ISTI'vti4E�1" p ��lorJ41 Aug Suev�/ac5
AND rNE oFFSE'TS 44C)O D u u- 13E a c�v I L E�1G111 EEC;
:Cl� T-p E5 fil�Ll {�zoPEtZTy l r N�5 5 TEfzv I LLc MA S4 .
APPLIC.AN-� �A�(SIL� �VILZI�G L"o . INC.
TOWN OF BARNSTABLE /
I OCATION b4l .SEWAGE
VILLAG'.
ASSESSOR'S MAP.& LOT
W.
INSTALR'S N YHONE N0. Jaev Z� '_�{fl
�..
SEPTIC T .1� CAPA ,: ]aob rg a
LEACHING FACILITY; (type)-'p.fl/� (size) }
::.:.NO.OF BEDIRUOAR-
s . BUILDER OR O a ;
PERMITDATI ,
COMPLIANCE DA
TE: - p -
Separation Distonze Bwwee►t.ihe
Maximum Adjustir-kn ;w:tle and Bottom of Leaching Facility�° .. Feet
Private Water Sep,ly ..t; } '•,;f ung,Facility (If any wells exist
on site or wit1 n 200 festr�i a facility) Feet
Edge of Wetland(ld Lee",�; r iB any wetlands exist
116.
within 300 feet of Feet
Furnished by
r
14
! Sri ' 1 �. � ♦^ � ' .. r _ ..51,
N •t � � . . •.. •
.� TOWN OF BARNSTABLE
` LOCATI 1�P- Co .6/ SEWAGE #
ASSESSOR'S MAP&LOT
iNST 11;NAI � 'HONE NO.
SEPTIC TAK CAPACCIYa' ,� �• (.r
LEACHING FACILITY::(type) -9eoo IJAL— (size)
NO.OF BEDROOMS
BUILDER
' PW t
PERMITD�'►Tfi _,3 C�c �iT' COMPLIANCE DATE:
Separation Distanze Between the
Maximum AdjusWd k� nC� t ole and Bottom of Leaching Facility Feet
Private Water Sad ly `TM ' hing Facility (If any wells exist
on site or with 20e'few �'.za ltgg facility) Feet
Edge of Wetland If any wetlands exist
within 300 fee t�of lei dg c �; ,t Feet
Furnished by
G '
953
G r I i i e• X • t I-
R
;✓ "�* ,x m�+r ,i, "' �"� � /j a A.� ` ' P`"� .,
�`• tea. �Yrl '�``� a �". � � w, Pig. ,
� � �•f f I
.3
AsBuilt Page 1 of 2
TOWN OF BARNSMLE
LOCATION b _SEWAGE# S`f?
VILLA( ASSESSOR'S MAP&LOT
IK
]IN STALtyR'SNAN19'�4PHONENO. ! *7,09-5
5EP1IC T�I{i�CAPA
v
LEACHING FACILITY;(type)�C�/� Ll�o (size)
.:jO.OF BELIROOMS ry�
UILDER OR 01AW-R•
PERMPFDA4., 01 ' COMPLIANCE DATE:,f - 2 0 '18
;Separation Distxn_e Bowecti.the-
Maximum Adjustcl&;.X KnF*+rttWble and Bottom of Leaching Facility Fee
Private Water Sar;ly".:�l.d`r':., twtiing Facility (If any wells exist
on.site or will n 20C'fealgt eat#`t facility) Feet
Edge of Wedandild LeztiS: ; ,iIf any wetlands exist
within 300 feet of lea; ;,g im ,,. Feet
Furnished_h� '. �a —
I
I '
ayq `ram+ .,c. ,cif. ��•
y:
�c
w
R rya •�.JL• ` s ..i .- a,f� s�� .
aA r.
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=252051004&seq=1 11/22/2017