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Home My WebLink About0230 CASTLEWOOD CIRCLE - Health 230 Castlewood Circle Hyannis P A 272 041 'f 1 r o � i N� i i a i jl I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 230 Castlewood Circle - Property Address : . Jeffrey Matsis &Aletha Webb 1k Owner Owner's Name information is .. required for every Hyannis Ma 02601 Nov-8-13 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... Matthew Gilfoy.. use the return key. Name of Inspector B&B Excavation, lnc: Company Name -14 Teaberry Lane Alf Company Address Forestdale : : : . MA::. 02644 : City/Town State Zip Code (508)477-0653 S113640 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15000). Thesystem: ® Passes. El Conditionally Passes ❑ .Fails q. Needs Further Evaluation by the Local Approving Authority Nov-8-13 - .Inspector's Sii4ature Date The system inspector shall submit a.copy of this inspection report to the Approving Authority(Board of Healthor 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 InspJF. ubsurface Sewage Disposal System Page 1 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments GSM 230 Castlewood Circle Property Address: ... .. .. Jeffrey Matsis &Aletha Webb Owner. Owner's Name information is required for every.. Hyannis Ma 02601 Nov-8-13 page.:e 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 ❑ Z 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? Werii built plans of thesystem:obtained and examined?(If they:were not.: ::. ® available note as N/A) Was the.facility or dwelling inspected for.signs of sewage back up? Z El 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 El . ® 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,); 2 DESIGN flow based,on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .. 330 t5ins•3/13;;; Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is y required for every Hyannis Ma 02601 Nov-8-13 page. City/Town State Zip Code Date of Inspection D. System Information Description: it 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: May 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: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 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: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Existing tank- new leaching '03 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: e019 Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good working order with no signs of leakage. Septic Tank(locate on site plan): 5" 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: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 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 32" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle ns Distance from bottom of scum to bottom of outlet tee or baffle ns How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good working order with no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Offcial Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 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.): At time of inspection D-Box appeared to be in good condition with no evidence of carryover or leakage. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 (25'X13'X2') ❑ 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 time of inspection leaching appeared to be in good condition with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 9 P Y Y CGM , 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 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 0 drawing attached separately 1 � I W W'J 1 I 1 A, A2L-3a'(�If A3- 'tol R S A . 0� `RDu's t ~< 1 � I j I U L ti l t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 132" 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: 7-16-03 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: no plan @ BOH 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 it w Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 230 Castlewood Circle Property Address Jeffrey Matsis &Aletha Webb Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-8-13 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE 2 LOCATION c930 Cq,5776-WpDD SEWAGE # VILLAGE-- �/r�N��S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHOf4E NO. 1A fi& CRWQ 775--.26 da SEPTIC TANK CAPACITY Cx ,SSTAz(; /6Z6 LEACHING FACILITY: (type)"�� /yje"AS (size) �1, 37 17 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: S 3 COMPLIANCE DATE: 4 3 D 3 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 sit e.or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any=wetlands exist r within 300 feet of leaching facility) Feet Famished by � d �{ NN o I � c IA a _ _ Qx l e No.O'er`'3 —3 (_ R-e V = THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for �Digool *pztem Construction Permit Application for a Permit to Construct( )Repair(-1-Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No.,,,?—?,o 04v-CWoo COwner's IV ,AddRs an TerI o. Assessor's Map/Parcel 7 01 D�/ / ��r'( J,41nl P j�/ Installer's Name,Address,and Tel.No. l l Designer's Name,A dress and Tel.No. A & B CANCO V14t(c r ^ 350 Main StreetW. Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building /2, S • No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow S gallons. Plan Date 7 f/��'3 Number of sheets Revision Date /V l Title Size of Septic Tank -eXl S ! S"" tv cs a Type of S.A.S. Description of Soil P< Nature of Repairs or Alterations(Answer when applicable) Pz F- 10 Ga--J Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by h' Bo o Health. gned Date o 1 s 3 Application Approved b Date IRJ 1 S 6 Application Disapproved for the following reasons Permit No. ';DL� 3 Date Issued S o. s ~Fie N Y THE COMMONWEALTH OF MASSACHUSETTS Ente !___red in computer: PUBLIC HEALTH DIVI$I� TOWN OF BARNSTABLE.,'MASSACHUSETTS Yes 01ppitratton for-Mi9;po9;a16petem Cowwuctton Verna Application for a Permit to Construct( )Repair(✓Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,13ej OA 5f c c,)oo C; r'" Owner's Name,Add"reds and T 1.No. Assessor's Map/Parcel J 0 ( .r,4/hV_ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. , CZt�Y�r SSS- 0) S3 p . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building t2e.S • 'j No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ?Sod gallons. Plan Date 'We.,/3 Number of sheets / Revision Date Title Size of Septic Tank ca Type of S.A.S. Description of Soil PC r 1)14"j Nature of Repairs or Alterations(Answer when applicable) P j l� Date last inspected- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ! in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo Health. r S . Signed Date 's .Application Approved bye Date g 6 Application Disapproved for the following reasons f._ Permit No. r�C�O 3 314 Date Issued w I T 5 U ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certiftcate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( --r6pgraded( ) Abandoned( )b at �'f (JU'• [ t'• Ar 4has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �_ 3-39 7 dated Installer Designer The issuance of thil eAnit shall not be construed as a guarantee that the system wil�.eti'f s��+gn• d. Date I,0 3 Inspector ---------------------------------------- No. 3,7 Fee .THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS x1t5po5ar *pgtem Construction Vermtt Permission is hereby granted to Construct( )Repair(v'�Upgrade( )Abandon( ) 17 System located at s U f=#Sf� L / ,�( �e!� t and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the dat of this Date: r6 I `� 'd Approved by TOWN OF BARNSTABLE LOCATION c9 0 (fq67Z6- 4icn o SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 72 —6�( INSTALLER'S NAME&PHONE NO _ 10?tt&CMJC Q 775-'d28 as SEPTIC TANK CAPACITY, 6v tsrJZS 16a� LEACHING FACILITY: (type) (size) g,40 NO. OF BEDROOMS BUILDER OR OWNE PERMITDATE: g S 3 COMPLIANCE DATE: il 310 3 l 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 I f I Po i i 4 a � Eck ' g � a 101 , i i �p III A Commonwealth of Massachusetts Executive Office of Environmental Affairs �i��E�� ® Department of �uw , Environmental Protection j9ss: William F.Weld HaLL PT.Go"Mor TOM OFSTABLE Trudy Coxe se., ,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: CA5T�1 �wC0'O.Cv � 1-�Y p y �,�Q � Address of Owner: �- Date of Inspection: 6—Ia c* (If different) Name of Inspector:--t:�oV -�� bc ,Company Name, Address and telephone Nu+mber: fc� CERTIFICATION STATEMENT .I certify that I have personally*inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: r. ZPa5ses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails (t Inspector's Signature Date: r Sfi The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. .;T The original should be sent to mc• system owner and copies sent to the buyer, if applicable and the approving authority. r,=y INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES:�Zl . have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. e) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. r lir.: :rit Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why;not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. , 4 (revised 6/25/95). One Winter Street a Boston,Massachusetts 02108 a FAX(617)SWI049 a Telephone(017)292-SSOO i~, Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,� C 45TC2jOfl G r-Zi�r�, 1��—(r Owner: eP0\'k0GK_ Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) 7 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will ass Y q P g Y P�l� Y P inspection if.(with approval of the Board of Health): ,,.. broken pipe(s) are replaced obstruction is removed 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 isfailing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER , WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. t; 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT;,,,. THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ 1 he w5tem ha% a septic tank ano soli absorption system anu 6 within i00 feel to is surfaCE Yvalei suaNIy or tributar-y-to a, surface water supply. _ The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well; r( _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for col iform bacteria and volatile organic compounds indicates that.the well:isy$ free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pPm• *i D) SYSTEM FAILS: l have.determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination-is identified below. The Board of Health should be contacted to determine what will be necessary,to corret t the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.. r _ t;ri y4x't�;�hlutt'; Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded,or clogged-SAS or cesspool. + . :s (revised 8/15/95) 2I Vol, •V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 a G AS't-V—Woao Owner: P o t oc' Date of Inspection D)SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. 17 Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i1 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design.flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health. and safety,. and the environment because one or more of the following conditions exist: 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! The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. G (revised 6/15/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addres :'3k.2 0 (Z AsT tE Low 6 Ctr-t'e_ Owner: P 01 k dck- Date of Inspection: Check if the following have been done: '✓Pumping information was requested of the owner, occupant, and Board of Health. _ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 01 The system does not receive non-sanitary or industrial waste flow Zhe site was inspected for signs of breakout. All system components, excluding the.Soil Absorption System, have been located on the site. Zhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. /The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by nun-intrusive methods. The ;Jn;,' occupants, if d;'fere^a from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. H ftY' H (revised 8/15/95) q .r, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:OL36 C A-3T L V 1'� Owner: ?b�tOG(L Date of Inspection: . FLOW CONDITIONS RESIDENTIAL: Design flow: eallons Number of bedrooms: 3 Number of current residents: o�- Garbage grinder(yes or no):,,� Laundry connected to system (yes or no):\/ Seasonal use (yes or no):-JL4 Water meter readings, if available: c Last date of occupancy:_�S--tv�"r`i i i-,,e yaw+ COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap present:'(yes or no)_ , Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspe ion: (yes or no)_�! 1 If yes, volume primped: O49 allo pumping gvnReason for 7- J Vvt• `•) TYP.E�OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool -s- Overflow cesspool v Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) ,;.et (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address-y ZO c�sTc.y c u,)oop tr-Xt- 7• Owner: v�6 Oc V Date of Inspection: SEPTIC TANK: (locate on site p aN ) Depth below grade: ,{ Material of construction: (/concrete _metal _FRP_other(explain) Dimensions: Sludge depth: Rio 1 { Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0i" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 14 (l Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet;:invert, structural integrity, evidence of leakage, etc.) ASCr I :--. J. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of --t— in hottnm of outlet tee or batlie- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural p'.' integrity, evidence of leakage, etc.) (revised 8/Y5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address; &-30 CASTI-a tucoo Owner: Po I l 0 L Y-- Date of Ins ectiori: TIGHT OR HOLDING TANK:L/ (locate on site plan) . Depth below grade: Material of construction: _concrete metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level. Comments: ' (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:- (locate on site plan) Jtgt1"� .Depth of liquid level above outlet invert: Comments: tnote ii level and distributwi. eyua:, e\ldence of solid: ca:r)u�er, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) �� I Pumps in working.order:(yes or no) t + Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) to;),. �s (revised 6115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address- 51,30 CASTIL C006`b G N-vk•., r Owner:Date of Ins�ecOtion(p LVC SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) 'If not determined to be present, explain:. Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: ' leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: - (locate on site plan) Number and configuration: 331rr) .4{q Depth-top of liquid to inlet.invert: Depth of solids layer: Depth of scum layer. ''.• ` }' ri) t •s Dimensions of cesspool: Materials of construction: )"•rr �''" Indication of grounclwate-. inflow (cesspool must be pumped as part of inspection) i Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) tc) 10Ai.1.1 PRIVY: (locate on site plan) Materials of construction: Dimensions: .a: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) �H (revised 6/15/95) B tri « ) R L� d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address- X3 O Cf3rST LL5 CL6)p GZ rt(--e_ •t4-r Owner: D t�(G Date.of-Ins ectioLIn: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' kr6, 0 w DEPTH TO GROUNDWATER Depth to groundwater:� feet . method of determination or approximation: ol" e'h 'k w" 1 (revised 6/15/95) 9 t,°+' ASSESSORS MAP : 21Z. TEST HOLE LOGS NOTES: z PARCEL : 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR : MP ep— F.5 (�E THIS PLAN 1995 MASSACHUSETTS TITLE V & TOWN FLOOD ZONE :% WITNESS : �+,IGr ( 1 `y '`—r OF - �J 1 K�aST✓i l3L.�' BOARD OF HEALTH REGULATIONS. REFERENCE : fjIL (oVO DATE: LL 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, G 7PERCOLATION RATE : L-2 �'^ /)tGA q SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO INSTALLATION. TH- I �1., .2° TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION 1 L-ot t ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE 1 " SP-�D (��'4�y DETERMINATION. 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS SPECIFIED OTHERWISE) LOCATION MAP(k►'T•S) D+ �D� 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A C�a KBE '7 GARBAGE DISPOSAL. SFl-�j 1 2 7$ 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. 7. EXISITA) LE 60 FiT AIMAE0 CAUSI�Et) _ o 8)No i v,�Tt wEu-5 �—SO PROPQSE) lc----��.� SEPTIC SYSTEM DESIGN �� A-- wERA Dom, - w�i✓I___.___.'OF {i2r>POS �_-- - �j..:___.._...-__ --- - /soy FLOW ESTIMATE J IJ BEDROOMS -AT 110 GAL/DAY/BEDROOM 336GAL/DAY 71 - ✓` � (o"Cxy Tf' 26R �c�v IbI �� SE-PT I C TANK �—� 382.- �D��! 0`'�1 P+T z GAL/DAY - y� x 2 DAYS C o GAL 21 USE ( GALLON SEPTIC TANK—,ff)</S7/A)e - ALA CJE W/ d SOIL ABSORPTION SYSTEM Z"ED ►avo4 S.T. _ --- . . . LON6.0/J A�L S/U6S f'Z� L x SIDE AREA: —25�2 -j - 2 k• 0. ?(/ = E-X l l2.�fg �. A, +5TIJjCt BOTTOM AREA: S� x✓3 R a. �v�- � �" �a•� SEPTIC SYSTEM SECTION ? 33a �f->I) '-e Cyr um s i SA mm to l� Ll � ,f - 9 �o �y 2% 3106 wGSh e force SKI ZVD-sox/f/.S�-��2 7Z DC� GAL (p G �ks* 1 _ Ye�R//' E(6 VI-no� SEPT I C TANK llrw �e%c 1 nc s� 6q. 6, g�J 4 S6, 20 �y DARREN SITE AND SEWAGE PLAN G _ VN . 11 tl LOCATION : 23� E G�9s lLGayoU,c� ��« UMBA s "O9 � sAN17A�\P , l °FFSS�oNP �3 P R E P A R E D F 0 R : gtio v �Q DARREN M. MEYER R.S. SCALE : DATE 43 VINE STR EET �- DUXBURY, MA 02332 DATE HEALTH AGENT (781) 585-0293