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HomeMy WebLinkAbout0022 BLANTYRE AVENUE - Health 22 BLANTYRE AVENUE,CENTERVILLE A= t //// J�QEcvcLJFn Illm�� 2 �fZ UPC 12534 No.2 1 3LOR -co HASTINGS, MN e Commonwealth of Massachusetts o?ag ooZ , W Title 5 Official Inspec ion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Sa oroschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: ` key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. Excavation Company �y Company Name 14 Teaberry Lane Company Address Sandwich 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. 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 f,110/ 6-15-15 Inspector's Sig ature 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 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 Zip Code Date of Inspection page. City/Town State B. Certification (cont.) a 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 1- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is Ma 02632 6-15-15 required for every Centerville 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 1/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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. r ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the - system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 349 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts o- - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: 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 see below 9 ( Y 9 (gP ))� Detail 2013- 131 000gallons 2014-18,000galIons Sump pump? ❑ Yes ® No Last date of occupancy: summer 2014 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner-date of last pump 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): � 2-2" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 14" 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: 1500 gallon 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 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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 30" 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? measured 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 septic tank appeared to be in working order,Tees present no sign of back- _ up.Liquid level equal with outlet invert. 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 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M y 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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 appears to be in working order no sign of carryover or back up. 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 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is Centerville Ma 02632 6-15-15 required for every - page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 hi cap infiltrator w/4 of stone ❑ 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 appears to be in working order with no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plah): 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17. Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 page. CitylTown 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•3113 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 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide arview of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I CO AZ - a3' A3 - -AV5", 63_ ayt a 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 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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: No Gw 15' 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 98 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: Plan on file at 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 22 Blantyre Rd Property Address Alex Saporoschetz Owner Owner's Name information is required for every Centerville Ma 02632 6-15-15 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �._.\ COM.NIONWEALTH OF MASSACHL'SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 2 3 DEPARTMENT OF ENVIRONMENTAL PROT ONE WINTER STREET. BOSTON. NIA 02108 617-292-"00 N > 1d 6 �y1S�bbg�0 MO G6 6 WILLIAN'F.WELD /V Governo: ARGEO PAUL CELLUCCI DAV✓✓I UHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM issioner PART A <� t CERTIFICATION Property Address. Z 2 Address of Owner: Date of Inspection: (p j �g'7 (If different) Name of Inspector: A.i_L 6A 4 am a DEP approved system inspector pursuant to Section 13.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address: soy- Telephone Number: 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: 7r !seeds Further Evaluation By the Local Approving Authority —_ F afM Inspector's Signature: a ,v lczz4b Date: The System Inspector shall submit a copy oft inspection report to the Approving Autho rih 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. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: l� I 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. COMMENTS: jh, S k4C(W t4 00-1-5 %c cMv c1E� C_ A _ W AAS p j 1��= C✓� �-c.v icf Cc-- a i� 6-- C 1 �.1 L� 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 proved by the Board of Health, will pass. V 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/lwww.magnet state.ma.ustdep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A i CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) 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). Describe observations: 6N�A t/ broken pipe(s) are replaced A��T� 7G S��— It'Z C�o 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 pass 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 is failing 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. 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation.not valid). 3) OTHER (revised 04/2S/97) Page 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z Z L- d--_� �,- AIQ)`— t G"= Owner: Date of Inspection: 9-7 DJ SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I 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 correct the failur Yes No Backup f sewage into faciIity-or-system component due to an overloaded or clogged SAS or cesspool. Discharge ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level i the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspo is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more th 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption ystem, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is w in 100 feet of a surface water supply or tributary to a surface water supply. Any ponion of a cesspool or pnvy is within Zone I of a public well. Any portion of a cesspool or privy is within 50 t of a private water supply well. Any portion of a cesspool or privy is less than 100 f but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been alyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia .trogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large Syst ) and the system is a significant threat to public health and safety and the environment because one or more of the following c ditions exist: 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-1WPA) or mapped Zone ll 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 atment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further informatio (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - CHECKLIST Property Address: Owner: ti`A Date of Inspection: _-G;1 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health. _ — �a + None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. L I in Nl 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. The system does not receive non-sanitary or industrial waste flow. Y — The site was inspected for signs of breakout. All system components,•ex� the Soil Absorption System, have been located on the site. CLti,Sr-IovC S ►a4Cl,t,ait�G- Ce�S�coc��-S — The se�cs�k manholes were uncovered, opened, and the interior of the set; 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Y/.Existing information. Ex. Plan at B.O.H. Determined in.the field (if anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 ' 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z 2 [�ljN Owner: —vrk Date of Inspection: lis I q—? FLOW CONDITIONS RESIDENTIAL: Design flow,: g.F,d./bedroom for S.A.S. Number of bedrooms: Number of current residents: O Garbage g,, .der (yes or no): 14o Laundry co-,nected to system (ves or no):VE S Seasonal use (yes or no): �n Q Water meter readings, if available (last two (2) year usage (gpd): /�. • Sump Pump (yes or no)440 Last date of occupancy: � > �� COMMERCIAUINDUSTRIAL• Type of establishment: Design flow:_gallonsiday Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available Last pate of o cupancy: OTHER: (Describe!. Last date of occuoanc-•: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) 14G7 If yes, volume pumped: Qallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system =r Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 'Hot- —�L) t L k t o I —�— 'T—A,k Ti ul,L _ Sewage odors detected when arriving at the site: (yes or no) � (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction hr-.E� Diameter Comments:'; r�oriit;on vf,,roirtts,'venting, evideote#,of+IeakagE^retcJ)• SEPTIC TANK:_ (locate on site plan) Depth below grade: material of construction: _concrete _metal _Fiberglass _Polyethylene _other(e/ain) If tank is metal, list age _ Is age confirmed by Certificate ofVeloYfe, o;Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet teeuid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fi/glassPolyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of o/teebaffle: Distance from bottom of scum to bott tee or baffle: Date of last pumping:,Comments: (recommendation for pumping, condiand outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT .? nk must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(expl in) Dimensions: Capacjty: gallons Design flow: gallons/da\ Alarm level: Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence/solidscaryove,, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or N ) Alarms in working order (Yes or o) Comments: (note condition of pump cham o pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 Z -f � ►�' �`« �� � J�/� Owner: Date of Inspection: (o/,G jc?7 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: Lot—, �L� O �� SY S � �►-�1 � L Alternative system: Name of Technolo 10 3� (jam �l�S Comments: (note condition of soil, signs of hvdraulic failure, level of ponding, condition of vegetation, etc.) X r�tx� G'���`�- AL_ l i L-t ST fvG— I Pk LIE V i=i- 2S b ", EE! 1 AJ CESSPOOLS: _ (locate on site plan) Z L tl Number and configuration: Depth-top of liquid to inlet invert: Depth of solids laver: Z 3" Depth of scum layer: (O' Dimensions of cesspool: Cox F' Materials.of construction: E3Lc_K Indication of groundwater: �4D N F_ inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of po ding, condition of vegetation, etc.) C' S$f�p0 C�-1 1u� L4 '�tiJS SI�OI t+v6 Uri CC �, tt t�icv ry 1��G t 1 Z� t YL .� 1�`o o�� t$f-"q� M �i i� i� '1�. l�fl l�] i tC�E PRIVY — — Q:F= 25; i. Q, L t�10� i�cv l_ i, (locate on site plan)- -H,� 1 GL� Gv Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: AN Owner: Date of Inspection: j S I g 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent.references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t� }-}C%353 cove �' : L 61x C - Q.; Z 21) 17 C--�� GAS eGSS�aol_ !s Ca,J i l4e: MIMUS ra OI- � SS �00 L I Z y Sc O L IF (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �_22> Owner: LA Date of Inspection: Q-7 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 1/ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own "vords how you established the High Groundwater Elevation. Must be completed) Slr4C! V%CD Gt��ac; t��i� CCAD ►=,�2i� t II a 2-1 C4 l iv--, GQR— AT � Sy S_"� �. (revised 04/25/97) Page 10 of 10 �r��' it I �s d `® ► d I Imo+ 1� • 1 `1 � ��'R`A • ' i 1 '/ �; ��� ill � r�OI 1 ,1ptl.�r1B �,\ � f�I t • _� I � ��rrr.� r � 1 � zqz: ENGINEER: BARTER do NYE, INC. BOARD OF HEALTH: EDWARD F. BARRY BACKHOE: JOHN AALTO CHING BED/FIELD �, y STRIBUTION LINES LOGS OF TEST HOLES P - 8570 BENEATH SYSTEM IF ENCOUNTERED 9/19/95 JUM DIUM SAND LAYER SAND PER 310 CMR 15.002 PERC RATE: < 2 MIN PER INCH SA i TH1 1H2 DEPTH ELEVATION DEPTH ELEVATION 0' 37.5' 0' 37.9' AO TOPSOIL AO TOPSOIL 1' 38.5' 1' 38.9' INVERT EL = 35.0' BO SUBSOIL © SUBSOIL END PIPE EL = 34.8' 2.5' 35.0' — BOTTOM EL = 33.0' P 3' 34.5' 3' 34.9' © SUBSTRATUM CLEAN MEDIUM SAND WITH GRAVEL n 10' 27.5' NO WATER © SUBSTRATUM CLEAN MEDIUM SAND 12' 25.9' NO WATER . 32 30 . 34 N g'22'30� E L O T 2 6 36 � . x LOT D �o Zs 38 0 154•�� ' �• 20,850 S. F. t x 33.2 50' (TO COMPUTATION UNE) 1� 6 4 ON TOP OF BANK ` I N Z o e _ 20' I ' I o� o z r ` in mr. OSED F AY ®GARAGE I ' I! o p> z 1 x 36. .J m �cyrn �v� ` 6.2 x 34,7 n c.+ 0, m m D � �g (0 m 1 ' x 29.7 aiT. > 00 0 � POLE #2 .9 v 9' � 10' � o o r t IZ ' \ �Iz 37.9 E c� CIEWERU E OF HERB MO DMCH TH # o 7-�^x if 28 ` r+ oo M I m it Q I 50 t OM 10P Off`B ZO TOP OF BARK m 9.8 IP 37.5 Z 1• x31.75� swA� 32 , t C � 7.6 x 3$.8 3 4 123 � (t1 8 3b 148.00 � W S 83-Of 45 c L T C 12" CONC PIPE 'A_.CB/bH lb EL - 37.6' L Q T 2 7 I 39.7' <n NGVD— 0 m o T.CATCH BASIN 0 0 Z m � v I Cy� I " N � C'. z v N to a N/F J N cm O J � . • O 4+ 40.00' No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mi-4pozar *pztem Construction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No.�"� AK-T Vc Owner's Name,Address and Tel.No. GTE- �`�'�_ Assessor's Map/Parcel •���y h\� �����® Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow n gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 1 QVy CGi DGn vt_ u&.t&L.t�—LATc� Description of Soil S VN1-J Yp Nature of Repairs or Nterations(Answer when applicable) \S'bz S:f v\ 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 Environmen 1 Cod d not to place the system in operation until a Certifi- cate of Compliance has bee x�su�- tof ea . Signed Date �l Application Approved by C- Date / 0"/7'/G 7 Application Disapproved for the ollowing reasons Permit No. Date Issued No. / / 7 .. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for �3ftqoml *p!tent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) %Complete System ❑Individual Components Location Address or Lot No. 4 Owner's Name,Address and Tel.No. Assessor's Map/Parcel O\ �� p0 d✓ t� 6�. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. O M-Gies 0-c-5 Q Cr� , Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 O gallons per day. Calculated daily flow _C::� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank k"':; �oA V__1 Type of S.A.S. Description of Soil 1416& .� S Nature of Repairs or Afterations(Answer when applicable) Date last inspected: * r Agreement: i 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 Environmen 1 Cod d not to place the system in operation until a Certifi- cate of Compliance has begnassued-by-tl ar o ea . �. Signed Date Application Approved by1*1 Z-11Date / 2—1 7- Application Disapproved for the following reasons r ' { f -�• Permit No. Date Issued - - - - -- -- _ - - - THE COMMONWEALTH OF MASSACHUSETTS C;11 6 - - BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded()Q Abandoned( )by 1 L7— �. 5-F—;Pvk at 0,VE L _'e- vt\ •_has been constructed in accordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the systetp wli1L unction as designed. Date Inspector �/ J---=—=--------------- ---- —Fee �� _ No. �a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ]Dt!5po2;a1 bpgtem Con.5tr etion Permit Permission is hereby granted to Construct( )Re (' )Upgrade(Y)Abandon( ) System located at A`>�.... and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pmt. " Date: 2 7- 5 Approved by // . I0/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only- 'CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby sertify that the application for disposal works construction permit signed by me dated concerning the property located at 1(_^ meets all of the ` l following criteria: There are no wetlands located within 10o feet of the proposed leaching facility There are no private wells within ISO feet of the proposed septic system 9 6 Vt/'-There is no increase in flow and/or change in use proposed There are no variances requested or needed. P (/•/'If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the (/ proposed leaching facility will =be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. _ Please complete the following: A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) / �/" B)Observed Groundwater Table Elevation (according to Health Division well map) e � / c7lu �.. 1 SIGNED : DATE: ^f LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:oat �%�- - ;r 2��� 0 . o v 1 �� r -� TOWN OF BA.RNSTA.BLE LOCATION ..... 6A, SEWAGE # ' 7 VILLAGE 11WAKA 17- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � P SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE:_I(j 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 I Furnished by PA r LOT 21 LOT 20 _ 148. 40' S85 33'14 W i 23'f h ti F-. 28. 4' �. o 2 Z\i p �� o LOT 23 "' p l w DECK LOT 22 cp 82 31 0 0 W 93, 74' S LOT E3 N 51. 00' N82*31 00 E S0729"20'E 5. 00 LOT E2 j RES. ZONE. "RD-1" This MORTGAGE INSPECT Ian is For FLOOD ZONE. Bank Use Only TOWN: _CUM L?EfU '---------- REGISTRY OWNER: . lCHAEL E SATERI----__------- IDEED REF: _ CTF jL450Z1_------BUYER: R-F1NANx ------------------------- DATE: _10223 98______----- PLAN REF: _L. C._ 17678K __SCALE:1"= 30 ___FT. I HEREBY CERTIFY TO HU-ty EST --- JGE__—__-- y�zt yANKEE SURVEY THAT THE BUILDING F, : `Oo� s SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS # �.» ;. ma`s CONSULTANTS SHOWN AND THAT ITS POSITION DOES ____ CONFORM :,,_w,:THi'31 TO THE ZONING LAW SETBACK REQUIREMENTS OF THE40B INDUSTRY ROAD �Y TOWN OF AND THAT s .t ' MARSTONS MILLS, MA, 02648 IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD �' - �.`�` TEL: 428-0055 AREA AS SHOWN ON THE H.U.D. MAP DATED19�85 _ �'*ti ;' 3�3a�' FAX: 420-5553 Com nit —Pa el 250001 0005 C THIS PLAN NOT MADE FROM AN .INSTRUNIENT �--- -- -- SURVEY, NOT TO BE USE 25818 CB PAUL A. MERITHE4Y, PLS D FOR FENCES, ETC.- �. � TOWN OF J3ARNSTABLE � LOCATION SEWAGE # " 7 ESSO R'S MAP &LOT ! VII.LAGE ��,�su�r ASS '12$s LP7,`„�� INSTALLER'S NAME&PHONE NO. '� �� TG SEPTIC TANK CAPACITY �OU LEACHING FACILITY: (type) � (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: _r 'L-r-7 -q T COMPLIANCE DATE: Separation Distance Between the: . i i 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 , Feet within 300 feet of leaching facility) Furnished by i - i .. i i � S�f fib► Id Q 12/03/98 THU 09:51 FAX 7039059045 Mlchael Pusateri 16004 3c. 01-97 TUE 10:06 Pn P. 10 ITJ001aged 86/Z/6 paSTna.z SUBSVKFACf SE-110E DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ProDem Addrrac: 01.ner: Datt of Inspvetion: _. SKETCH OF SEWAGE DISPOSAL SYSTE" ir.dude ut:S to 7a le451 twlo permantnt rvilrvncoS I:n marks or kw-mOrrurks Iocble i{i w!{u tii(hr. ) i1.G=0 .YI!'!r?ubtir�'e!ir a�intrfr Comes Into Nou") Al a st= �GoJ�� • �t i�, Mgt, �.. I 12tr 1 _L 1? ►•�.► o'TG-' 5Y5T&n�f .�'Z � Y•�•Z•�M a� 'Z 13 c.oN S frm c A-s 2 _ . Ao(esnoy oitil setltGo Alddns M 0 I 84Jswy3uaq i s>IJewpue�ueJegLy�Irrtl gt�rwy Lst is o�ser3 epnlo t,- :W31SAS WSW= DVM3S d H013)IS 8 6/0 T/Z T (swsred w/�s/f)) save a as 3oT3a:12Snd TaugOTW :JvuMO • SSBW' aTTTAlaqua0 any @Jz lusTS ZZ :S-JPPVAVOftJd (P&nuDuoo)NOLLVWUCUPM W31SAS 3 IUVd WaOd NOLL03dSNl W31SAS JVS0dS10 30VM3S 30VdunsonS