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115 Buckwood Drive
Hyannis, MA
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Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,..'¢ 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be.altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones Y
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
Company Name
74 Beldan Ln.
Centerville Ma 02632
Cityrrown State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
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
6/4/2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
TOWN OF BARNSTABLE
LOCATION //f 'a,j CKw,%b A1( SEWAGE#
VILLAGE H ltAiyNl S ASSESSOR'S MAP&PARCEL 2-7 090 r
' &PHONE.NO. K D�j���5 ��t� ���d��3��1 N507
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) P
NO.OF BEDROOMS - y
OWNER W I Wwam MVUA!J
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet _
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
.. ...........
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
'<0 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is
required for eve Hyannis Ma 02601 6/4/2013
Q every
page. Citylrown 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:
The dwelling located at 115 Buckwood Dr. Hyannis is served by a Title V septic system consisting of
a 1000 gallon septic tank and a 1000 gallon precast leach pit. The system was found to be in proper
working condition at the 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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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:
i
❑ 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 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**..
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 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
115 Buckwood Drive
Property Address
William Murray
Owner Owners Name
information is required for every Hyannis Ma 02601 6/4/2013
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
❑ El 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
115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
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
G M , 115 Buckwood Drive -
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
J
Number of current residents: 1
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 Z 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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:
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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:
original system
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5feet
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.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
6" �
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
115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Cityrrown 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
3"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle 6„
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
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•3113 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 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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 N/A
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of inspection the leach pit was found to have 1.5'of available leaching with no signs of
past hydraulic overloading. Cover is on a riser 6" below grade.
I
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
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Citylrown 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 115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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
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A_3= 3-2
9.31 31 �
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
r
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 115 Buckwood Drive
Property Address
William Murray
Owner . Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
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: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Buckwood Drive
Property Address
William Murray
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/4/2013
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
T
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TOWN OF BARNSTABLE
LOCATION h r 'Ki CKwoui�, SEWAGE#
VILLAGE yAN N l S ASSESSOR'S MAP&PARCEL Z7 09 0
INSTALLER'S NAME&.PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS y
OWNER W L I,/a m✓LEA'`7
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
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Passes s
�-- Condifion�Y Passes
FNeeds Firth l;vahntioa by the Lood Approv aB Au
dodty r
Inspector's 8ipat c:
the system itispcctout shag sn6 = .
Date—
D-tP)witf�30 days ofco Icy a easy p ti inspection=FOrt to de
vinZ
gpd or c r°P S this inspectioQ C#'the sYstcta is s sbazed ro AuthorLY(Board of Health or
DEp, Bxratc,.tl�c mspe for and the ay�tam owaer shall sucport nit.or hae a
surban LC� �should be sent m the systems oWncr and��sent to tiic bu the apF�P�tI I Mg onall flow
f$ae of dla;
Ya.if applicable.and the app
winS
Notts and Cav=jeft
"• 'Ills report only daccrib s conditions at the fine of Inapeuion sad
HMO-This invecfidrz does not iLddcess bow the aysts�wm � trader the cagdl
coad,66bs of Yte. P dorm lira a Dons of Use at that
�iNh@ filler the aame'er diihrcat
Title 5 rnspoczion Form GI5tZ000
page 1:
t�Ud ate oe75
Page 2 of I 1
INiSPAMON FORM
g 'N VdL
UltFAC� 'wAG$p�PagAL 8ya►RYAS,S�� ghS
II1T�P;�G-TIpN�,�.
PA$TA FA=-
C-ERTINCA,170N(coapmpcd}
Praperty Addrm=;
Owner:
?Satr ofMspectioa• `
IMPection Summary_ Check AB,CJ)or&/ r
';''!'r complete all orSectdo4 b
A• System passes:
.> I halve nor frndd any information whi
I3.303 or k 310(2,m Aqy!'iiIurc IS-304 exist. it �cs[rs cbaX any,of the faihnr Cr it &dcscnbed is 310 CMR
a7itet not Uvalaated ate and below
Camutgn
Sy9tem coQa��o�yp,�se;;
rep or mare syi+mn coWonaats as deseribcd in'he`
V'M cOMPTcdon of the 'conditional Pans"e=ttiaa read To be xcple=d or
} KP went or]:Vzks ar approvcd by the Board of Health,wdt e.
.` �yam,MO Or nflc ed(Y.N�ID)ut the_for
Explain- ft&Qotviag ante if'�tot d
p�eaue
septic t wk is n=tat .
TMG=i,.exlubit:,d M fie ° vr0 yem old*or the septic aLuk
aastutg tank is replaced with ae "iDation or t"*fw=fa �eraI ar not) YkTiet y
`A mcLl x tic raalctInk as nettk Sysnem
indicnti>z that the wilt ass-cramp �t{cYFP ,�by the Board of HH+rai Pasar,asaec#con i#'tbc
P �pcctioa
Stsaic Iefa than 20 yeas svtIabio.Sound.rat IcajdaS Md if art Cate of Coraplsaace
ND exPlaia:
_ Obsez~ratiaa of atwagc.backup�
obshvctcd P3Pe(5)or due to a b break out orh�igjt a ma evel m tv disttx�tian box due to
approval of Hoard oraca1th): CO •setrlod or UMVCU dicta ba<oken.or
ox System will pans kspcction if(with
broken pipc(s),r
ed
obstluctiotal is ed
distribution b Is leveled or mplaced
ND explain
xhc::yat�mod more th'�4 .
F t if(with of the Board.ofH�)a Yc'r tree to bj n�or a6�,csed p ).'Ilse system win
broken p*f9),rc KEplaaed
--�_obstuction uJ ND zsmokcd
t
Lain;
r
•RHP C Tn
- ---- -r - ,��� , .4, •�ri �n i nvrcd 'ic� +599 419 0875 T4di. r o04/OOb `F-438
- Page 3 of 11
0MCUL INS'PECITON M -
8U 3ITRFACE SEWAGE -Nor FOIE VOL
cE DISPOSAL SXST l►%ARYASSES�sMENTs
PAIMA -
����'CATTUN{cenm�toc�
FIVErty Add,..
Date oCln=pectian:
Further>FvaluatloR RequirQd by the.11aard o
C Hczlth.
""ityans exist which require Luther evaluatiodon by the
v Fig roteckpabIie baalrh,safety or the eavi poard of HcaM in order to detct03j=if the sysmm
X. System Est ti
P messkaard Of1kalth debetmTn.a 1n ace
ayattita V thacttoniagIna ancr�vldch�vtll rp "41m c Wth 310 OM IS303(x)(b) at the
p tcctpublic hoaltb,aafetgand the euvfri eat:
.` Oesspool is within 50 feet Of-a
surFacc water
Cesspool or is a+it6iu 5d feet of a bordering vegetared wen and or z salt mph i
2. Systmu will fail waIeaa tha Board o
th iYstetn is I ctioalipg to;manner that r ecdf and public WAtar Sup „If any)d■tarmInca that the
P me public hgttd, and environment: -
7hc sS'STcm ban a ecp6c tank and son
suzface water suV]y or tzzbtit y a cc don ( and the SAS,is WiGn 100 feet of
upp1Y-
a
The Sysee,A h"a saptie tank and SAS and the -
widin a Za=I of a public w=tzz svpp�y,
Tkc System.has.a septic tank and SAS.and the is
SO fcetof a p bZL-a+ater supply Well.
The systrm has a Septic tank and SAS all
pnvaw water supply WcA'�•,Method tt ¢ SAS is less 100 fort but 30 feet or 1 fivm a
amine distance
�b aYUCnI pores if the wen
bacteria and the p of sNe o�n�c compo indi .that t}�cawcII i9 Erne hbO"ate'►for celifnxm•
amiriooia nihrosc/,aad tntrate nitrogc i is ft+nm liam that facitity Sad
fatlurc crZteda ue higgc=d.A of the cqua to ex lays tb,a S Pmvidcd that no order
.��� �yzis u�be:mtched to tins fom
3. Other:
i
7
- ---- "---- _, ,�•� .�.,, +506 aZB 0B 5
7 T-5n2 "r.u05/00� F-438
page 4 of I 1
M�CIAL INSPECTION FO _
URSURFACE SEW, T- NOT R VOLU�AXV
SE$
PART A Y51`F pECrIog tt46i .
s CERTJRCA,TION(cont metp
Propexry Address;
Dwrrer�
DateD. of xiLcpeedop_
U
stem FAI[ure Criteria applicable to all
eyes or ao systems;
You tn
�t mdicare to Cach of the following for,v[; now:
Yes No
Baclarp of aewa ge into facili
Discharge or p o rY or systctm cosVa�eat due ro ovctloadcd
Clogged SAS or ooi cent to the surfam Ofthe ground or w clogged SA,S or Ce,��l
Static liquid level in the dis �rfacc��dt�eo as Overloaded or
cesspool uxb,rdon box above outlet invert duo to an dcd or cIo
; R'gd`-'tb`in��oI is leas 8ged SA5 ar
. than 6' heIew invert or svarla�
o Pm mg more ft 4 times in the lrat year OT due coma fs Iea thm h day flaw
to clogged or obstmCwP'Pew-Nambcr
Auypoi'rioa Of the AA3, cesspool or
J Any parrkmofcos P YY belowbaghSrandwaterelevation.
spoaI°rpriv3' aittria IQO feet of a sttc&ea waterPIY
or water aTFplY-
AnY Portion Of cesspool or mY rO a sutfnce
Pri is v�ithiri a Zone I of a public well.
� �YPottion of a cesspool or privy it within 50 feet of a�.0 •4nYportinn of i a"pool orp6vyis lest "`' �ta�Pp�Y gvclL
s"PPly well with no acceptable water !00. but�W than 50 f�kam a
Periarmcd at a DEP ` t3'analysis. P yn►are Water
e�tlfled tabocato � m aases,tl'the wail water an
Iadicatr=that toe welt.t:het hom ry'far cMifotm 6aetaya s+dtd 1ralstUe o ��'
nitrogeo cad citrate Pouatian from that 6cfli �M[c epimPo� s
n[t irfic is equal to or less than 1Y shd the presence of aranwAioa,arc triggerrd..A co al the a pPm,P id.d that t1a other failare P3' nilysis mast be attschea!o this[o►rro.I lt.12
i�li (Yas/Na)The"ein A
descn'bc,d is 3I 6 I more of tltc
4iR lS 303,dirtefott rbc sy3 g. aboWc failure cdteria mw as
$eaitlt to dc6ct tm what will be accessa +to catrcct *'I owe Aould contNct the Board of
Largs Systems:
70 onsidered a lar t stem be
Yaumust in ithcr• sY t �systern tltust serve;factUfy with a d"IL p,flow of IU.000 gpd to 15fluo
(The tnlloariag cti I s °r`no to each of the following:
3' lie Mtettm is addition to the criteria•above)
Yes no
-� the system is within 400 feet o
ce ddnlabg vary
_.. �_ ebb system is within 200 face of a - :-
• toga drialang Na[tr stlpply
dc�c svm IT Is loeaG�vatet mtrageQ�eosi4lvc ana( CC im WeIihea
UTPIY wo an Ara-1WPA or b
) moped
If You bavo_"wcred"yes"to t1°y 4
uQstio
"Yes"in Section D above the a in 3ectioa E tbt syjtmm is c
3�eant throne under Scctioa EE corm faiietj P for of-anyd iT �°r aaswerd
The f4M under Section 1)�� o arc aYs�m co
15.304. system owmr ahwb2n
oald eoaact the Vpmp�tc re6omai--ofllce the Depaciraent 3 0
r�Iw C T-�o..nr►=nw�nr�..G/7 crr......-.
t60H 429 OBT5
. r-43B
pages ot11
aMCIAL MSr. CnON FORM--NaZ Foe VOL A '
SUESL FACE SMAGE DDT UNTA cRY,A,ia Egg 1vT
si�s nvsri ,oµ s -
�C�IST
PropeKy Addrm
Osvncr.
Date ofInapcctloo:
Check if the follow* have been clone.You mast-
dicatc or ,tf as to each ofthc fnllo
J Na
Pis Vint i mfon=tioa was prodded by the owner,o aL;Or Board of I3callh
Ware any of the system
=3VoncDft.PwnPcd out in tha previous two W J,2,?
— Hss the system reeeivod nomml flown in he Pncvia.n two wciek Paiod? .
Tuve
laxga volumes of water been iatmaduced to the sy st m,rectally or as put o fthi!,erection?
Were as bull[plan9 of the
sy9tdm obtained and
minQd7(7t tbCY were not available aat,as WA)
i Was the facil W or dwelling iaspocted for J s�i$ns of"se bards UP,
— was the aite inspected faz silos a fbreaic
— out?
Were all aystcm componeam "alu�the SAS%located as site?
Wcte the scpac t2l*ttnnholca uaCQVrcd.o
of tha bifaes or t=%material of consCucea Fed nod the iatmlor of the tan inVoctrd for•tltc condition
4 dimcasions.depth of Ifgdd,dopdt ofsltycige tmd ffi of scum 4
--- �Vau the(acidity owner(arvd occuputf�if .
mainta cr of 6ubsuaihcc sewage dislpowd s ereQt from owner)prodded with in a tfon on The prQper
ystems? .
The size and lac uoq of the Soil Absorption S sleet(5 an the sale Ilea 6
cM yy9 nod based on,
V� O ng oz8a�ms nocL For tx=Pic,a plat at dw Board ofucaids,
C1 .
bcteTnined is dw FmId(ifaiyr of the fiiiurc aitrsia relatod to Pan C i9 at iasuo
is'Oc-cptable)1310 CMR 15.302(3)(b)l =PPfOximItiou of distaooe
'T::rL C i..o..o,•,;....�nrrr.G/T cnnnn
C
---- -----. .., tM 429 Q975 T-5a�' ' �oz/nob '-L 438
Page 6 of 11
0MCIAL INSPECTION FORM NOT FOR VOL
SUBSURFACK SEWAGE DMPO�s_YSrEYVi �. 0 s
!SYSTEM Da tNunoN
Owner:
s
Date of InapGcdoa: b
R&SMXN,TiA.L FLOW CON7yMONs
Number of bcdraoms(desip):
I7 Sdt;�flow�a�cd on 31Q Number ofbedi,00mg($ct.D: Y
N ur6e>;of 143(for example_ 110 gpd a#of edrooms): 1�cuzreAt=esideuts:_�
Does rcaidcn t have a gatbVc grinder
(yes err ono):j&.5
La►��y.Ozl i 9CPAI1IC scivw gyq[Cm(Yes Or UoYvx D rtgY�Separate 1�CCtYaA
Laundry aystnm iaspaCticd CM or
Seasonal h2t.(Yox or no):w
Watts meter readings,if availahk ast, cars
SUMP P=P(yes or no)h 0 {l Y usage(&Pd)): .
Last date of accupteneyr
CoMMMCZ UJM STRtAL
Type stabiicar.
D.. 911 IIa ed on 310 13.203).
Basis of dcaigrt tlo anPls etc. . d
Grease tra qg' )
• P presaint(yes or no ;
1 Industrial waste holding link present
Non-dlnimryw utc ftcbargcd itle5
Wier Merex reddings if a rAt na Ctrs or no):a
lc_
Last date of necup
OTHER(dcsctibc)_
Pumping Records GENERAL MORMA-noN
Source ofi fMMtiaa:
WAs Systempnarped as part of the�pcztioa(yra or no):
Re _gyp
yea, vvltmee put�cd: Hour was eluauti4r
ason fox pumping Pad deMMmihed?
T)PE OF SYSIEM
JJ Sep" b* "Rsftfieft ,0le.soil absorption system
Siu&cesspool
_Overflow cesspool
Privy
Shared s"tvtm(y=or no)(if yes,atm h
InnovativefAttcrnativc tccbnolo C4
A Pzo�> �om °�'
obra�ed from system ownar) e�a copy of the curYtnt opCmdon and-sintcnaiucc conh=t(to be
Tight ua Attach s Cepy of the DEP approval
Other(descgbc):
Approximate Svc of all ea Qtl. a iUxbd1
(if bsowa)and samrec of atfeMn4om
1�7ue sewage odors detected whca aaivirtg at due site
. (Yea or ere):
741.t T�:ew..►inw 0C _ ,
7-439
Page 7 of 11
OFFICIAL MPECnON FORM
SII.39URFACE SZwACSE IgSrd 'VQ A W ASSg -,
PAST C
SYSTEM 7NFQRMA'noN(canevmed)
Property Addretr. nn
Owner: _
hate nrin pCCH012-
BUILDING SEWR GOCau On site plan)
Depth below gmdc_
MI Ter'Lh of copsfluction: cast ftOm _40 PVC Jorher G
D Ce from Fivam wit" WCU or=Ctioa Zinc, (explain):
Comments(on caatutlon venting;cvideacc fir
SEP=TANK,(locate an site per)
Depth below Wide; �C t
M,¢teriaj ofcoestmction_•Lconcretn_=v1I fb=ZWs _ AolyethYLcue
Othrt(cxpjRjn)
If teak is,metai list age: Is age ca
certificate) ( mtd by C-'ett�ifeatr Of ComFhH2=e(YC8 Or na). (ash a copy of
Muensinm:
Slw1s depth; c r
scs thi team top of slv w bottom crf out tee oubat�:
Scum tIuckncas:`�_
17iatance Brow top of ac►1m to top of nudct tee or ba$}a-
Iais=ace tlnm bottom of scum to bottI
f ou t tee bane: _ t . ■ C► ►�'lC�,
How wsct�o dimmiom do
Cat=cr a.(on p»piag rcco�dn irniet and outlet tcc or 6aff1c ei related to outlet csddeaoc ot*ita�gc CCc. . � ttna1 ietcgrity,liquid levels
)-
OBE TRAP:(lorntc on mitn pliio)
Dcp lose tde=
Material
(���: _coaczatc.____�l�bci'�lasa—pb1Y�,Y� orbs=
DimeuYiom
Scum twclo
Aisraacc from tap of sc p rep of Omic baffle:
bistYnce frontbottnm of scum to bottom of outlet
Pare of fat ping; c•
Co
nlm°ats(au Perms trenmman& - of anti oudet tee or be$lc
as rcLltt d toouIict�v¢t�cvi leakage,of ,ccc}:
leaks x1 intetdM liquid levels
:
'Nr�- c T••••rw:.,.. t'n.-w rG/i GhMl1 7
�+-c
- 9
., n�m ...rn inr nrnnrn i iw �I1 1�•• "' rJUO VLY YO10 1—T - ',�=UL/UUS "'4.]S1
OFFMAL INSPEMiDN FORM-NOT FOR , ' ARYON
1 SYJB� TW'4"SEWAGE DIBPbf FOR
URM
i"TC
SYSTEM EMRMATTON(coulinucd)
PropertyAddreaa:
Owner:
Date of Iasptctloa-
TIGHT or FOLDING TANK.` (b�must be pumped at time of inspcction)(locate on sire p�
Depth below -
Matezial Of co
mcFal�$6apls9s�pojy *yl
o6:(cXplaiq):
D�casions• _
Desin Flow:
-Alarm present(yea or no)_
Alum love]~ is""dug order Cyn or no)_
Date of Iut
Com me (condition of alarm and float swaitelxcs,eW-):
is BOX; Wgzr =nest be opcued)(Iocate on aitc plan)
D Above t invert;, t(
ts(MIC I sad distnbutian ontic ,say�drnca deoc.o of
Ic c Into or our of b , ov#
PUW C at; to on sihe Plan)
e g order(yes or no)_
in woloug order(yes or no);
ommcnts(note eouditioe of pump chs�mber.condition of 9 and
PAP a P,pntLenAttces,ac.):
/ I
- •... •.•-.. .I.___•....._..._ ,.,..Y iYY YYId 1 Y. v .VJVV/YV1 j.J YYO
NEC 9ofII
OFF' II , WSPEIMON FORM—NOT]MR `
SUBSURFACE _,: ExNTARY ASB SA
sEWi#GE DIS�(�AL$Y�Z'�EM�I3 -
. Fn •�. vi.R .L\•� lili
per e
sYs �'a�aarxox��,�
Property Address: IDC-
Owner:
bate of atpection:
SOYL,ABSORPTioN SYSTEM(SA►,9): (locate OM site plan,IF!xr 0ztloe oat rogrsircd)
Lf SAS not located explain why:
�Tleaclag Pits,number. I -
leAching chttmber3,timber.
Ic=biag Qdllaies,number.
leaci:ing tremaes,numlicr,Im9th.
Icaching flalds,numb,dimeu�otu:
overflow cesspool,munbbet:
iMw'M vvalrecnariva ass% ,,Ypcfnamr oftecl=ingy,
Comments(note ennditioa of sod,sips nfhyd=auuc fwUre,level of
peg1IT13g,d=V BOIZ,eondidon'of vegetation,
CESSPOOLS: (ccsepoW nst be p"Od as put of linspo o '
a)(loCatc ou site plan)
Nhmber as lion;
Depth—rap of iiq inlet invert
Dtpth of solids Dyer:
Dapth of sc=layer;
Dimemions of cesspool:
l�atcrials ef+;anstntcdon:
kdic tlon o'f&t'oundVftb=infI '(Yes ur no):
Cnmmmts(node conditioa of sod.signs afhy/draulic fa�ure,
of g,condition of vegetft6oe,etc,):
• 1
PRSVY; (locate as Site plan)
Matey a ofeonsttuction_
Drmepsio�s:
Dcpth ofsotida:
Comments condition of:ail,signs ofhychanUc figm level of
pending condition of Vegetatiou.
741-C Twan.Rinn T:...... L/i a M....•. w
O
�rf:.�t Y•'i tom)-va_•' -
� t �� roars �Y
1
SYSTM
PmjwmyAd&"xt its �u3 b
Date of 1wPec font_ S _
S=C$Olr S£WA(;E DISMSAL SYS "I
PrcvJ&s ikstch of the sewagt disposal*%t=includfmg ties to ai lam z"pc=ancmt ir6 m lft* Tks or
be=bmark-t.Lam all wells within 100 feet Lac=whams public water supply tetras rite btuRding.
v
P!Z- 2"7'Ga 'j2--
t
JUI1-I. .... ......m ..._... nw�.•..'.::_::_ -...... .-�... .�. .-- -- ---- -I IV. IU-7
of 11
OMCIAL nvSMcTTpN FORM
s w _ -NOT YA -,NOT SXSTEMOLU SAkY Asµ
s
IiCFO
SYSTEM
MIMRXfi ATION(comma
ProPcrty Addreu.-
Owner.
bgtc ol'Inspcctioat
F
SITE EXAM
Slope
Surface wetea
Check celiac
sba m was
Est a=tcd depth to g and water feet
Pieme indicate(dicck)ail mtko&used to detcamine the Mah gmtmd water elcvstioa
Obtained Srom.sysccca desigaplans on record-Tf
Observed sire(abutting Pr0pcnylabscn%d3oo bnlc dace of dc4gRplaa:evicwe�
C71eeked with 1oid Hotvd of Hmlth acplsia; �vitbitt..l SO feet of us)
Cciced with local excavators,ins _(a d a
..�AcGcsacd tISGS daabasc-cxplaj3�.
Y mutt des c how you e5ts ' he the Izi h
V g and water eI lion:
45
�'=r10 S T....•...nr�nn k'......�l7 cnAnn !1 2