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Home My WebLink About0032 CHADWICK AVENUE - Health 32 Chadwick Avenue Centerville A = 246 - 057 SMEAD No. 2-153LOR UPC 12534 smead.com • Made in USA we�`yE.CYC�O C 2 m � z �ST.�OHSS' C� RBER USED M TENS PRODUCT UtIE +✓ ' REOUIRFA1EN15 CF THE SaPROGRAM CFRTIFlED souRCJNG VJ{WiN.SFpROfiItAAILORG Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 32 Chadwick Ave Property Address } Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019; 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. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address Teaticket Ma. 02536 City/Town State Zip Code »n 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ,I'- zaz 07-18-201 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This 3 bedroom home has a 4 bedroom septic system that was installed in 2000. There is a H-10 1500 gallon septic tank and a H-10 D-Box feeding 3 leaching chambers with stone. At the time of the inspection the leaching was dry and there were no visible signs of past hydraulic failure. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 'h 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 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: 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? El ® 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form I,; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. !/ 32 Chadwick Ave V� Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Plus, GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® 'No information in this report.) Laundry system inspected? ❑ Yes ® .No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2018 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ �No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ 'No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons t i How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 i , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: i ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy I ❑ 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): Approximate age of all components, date installed (if known) and source of information: I 09-11-2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 21" .Depth below grade: feet i Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet � I Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i c , Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Chadwick Ave V� Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 12" 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: standard H-10 1500 gallon 2" Sludge depth: 34" 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 5" 12" ' Distance from bottom of scum to bottom of outlet tee or baffle ' How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of the inspection the tees were in place. I k i i f t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form +_ lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is Centerville MA 02601 07-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): i Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i Scum thickness Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): g I I i I 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... !% 32 Chadwick Ave u- Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 1 Alarm present: ❑ Yes ❑ No i Alarm level: Alarm in working order: ❑ Yes ❑ No t Date of last pumping: Date S Comments (condition of alarm and float switches, etc.): t i I I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): I Depth of liquid level above outlet invert 01, 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.): i At the time of the inspection there were no visible signs of leakage. i it I I S# I i t i I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 1 Commonwealth of Massachusetts a Title 5 Official Inspection Form �I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Chadwick Ave V Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is Centerville MA 02601 07-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: A i t t Type: I ❑ leaching pits number: ® leaching chambers number: 3 t ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system , Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 } t I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) q f Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ' At the time of the inspection the leaching was dry. , t 4 i r 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): o Number and configuration ' f Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer i Dimensions of cesspool { i Materials of construction ` E Indication of groundwater inflow ❑ Yes ❑ No i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f , I i t i I i i 9i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f ! F i I G cam, Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is Centerville MA 02601 07-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , 13. Privy(locate on site plan): Materials of construction: Dimensions I Depth of solids , Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f I e i r z++ i t 1 i I i t I � F , i R a t I E I t I t i I x I I I r t t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 E Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference a landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: I I ❑ hand-sketch in the area below I ® drawing attached separately � t r I P 4, i f i t r i t f ' � I 1 i I 7 t I t t i I � { t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I i . I 1 TOWN OF BARNSTABLE E' LOCATION-3aZ C��dltz+;r�C A.ffc SEWAGE# ' VILLAGE tJCS� IIII R.,Ui5 r-R Ar ASSESSOR'S MAP&LOT INSTALLER'S NAME 4 t PHONE NO.RObi,Qur iiG. -77S—S?77(s I SEPTIC TANK CAPAd1 L Y ISoo LEACHING FACRM. (type) l-*Os (size) 2 z*� NO.OF BEDROOMS elCQt7� Sys/E/rl BLILDER O '. PERMTiDATE: 136 COMPLIANCE DATE:- briaoma Separation Distance Bet I cen the: ! i Maximum Adjusted Gro dwater Table to the Bottom of Leaching Facility Feet Private Water Supply W 11 and Leaching Facility (If any webs east on site or within 200 few of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le Thing facility) Feet Furnished by F 6 I � 1 i g O CI E i I ; i 1 ' i Commonwealth of Massachusetts Title 5 Official Inspection Form <II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells ; Estimated depth to high ground water: f plus feet l feet `• l Please indicate all methods used to determine the high ground water elevation: E ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) F E ❑ Accessed USGS database-explain: j P You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit to show four plus feet of seperation. t ; I I k a i e 1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. i l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 ; 4 c Commonwealth of Massachusetts ! Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 32 Chadwick Ave Property Address Joseph Coskie Jr&Amy Coskie Owner Owner's Name information is required for every Centerville MA 02601 07-12-2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ; ® C. Inspection Summary: ¢t i 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed , ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached t For 15: Explanation of estimated depth to high groundwater included vj 4 g i / a e i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 , i r r,� _ Y i No. Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Xigpool *pgtem Conotruction Perron Applic 'on for a Permit to Construct( )Repair( g)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ��ttjj Ad s� 1v gg�� aa��nnGG,, e�V 3Lo°� as W1CKo'Ave. , W. Hyan isport DWnY 1nipmSHoward Assessor'sMap/Parcel 200 Great Hill Road, Installer's Name,Address,and Tel.rTo. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system c on s i s t i n of a tank, D-box and 3 concrete leach chambers with stone all around. 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 thhs.-BozWd of Health. ® Sign 1, 1 /1® Date 7 Application Approved by - Date Application Disapproved for the following reas Permit No. Date Issued No. Feb 5 0 . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ry p; Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS RpOication for Mtgogal bpgtem Construction Permit � a Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System El Individual Components Addc r�C Lo�satl'on`AAdga9t �io.Ave. , W. Hyannisport °W°ph�' `iipre Iowan In Assessor'sMap/Parcel s�� 200 Great Hill Road, E t E. Sandwich Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. 'Robinson Septic Service P O Box 1089, Centerville Type of Building: s . Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) �= Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ' Size of Septic Tank Type of S.A.S. Description of Soil a R_n d � Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system consistin I' of a tank, D-box and 3 .concrete leach chambers with stone d arouna, 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 iss ed by Bopd of Bealth 11 Sign 1 A ty Date Application Approved by v Date Application Disapproved for the following reas61 t Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ' Howard Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )b Wm. E. Robinson Septic Service at 32 Chaydw C Ave. , W. Hyann sport has bAoconstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated Installer Wm- 1~. Rnhi ncnn_gr, Designer, The issuance of this pe • t all n f be construed as a guarantee That the!Eeir..will function de igmed. Date Inspector . No. ------------------------Fee$50 -- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Howard mo pozat bpgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at '42 Chadwick Ave p W. yanni sport 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:Constructiontz/ e co pleted within three years of the date6e7it. / a Date: t_/ Approved by t 1/ " NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) William E. R bb ins on,5, hereby certify that the application for disposal works construction permit signed by me dated ��-` � f , concerning the property located at 32 Chadwick Ave. , W. Hyannisport 'meets all of the following criteria: • The failed system's connected to a residential dwelling only. There are no commercial or business uses associated the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. There are n wetlands within 100 feet of the proposed septic system — There:tr no private wells within 150 feet of the proposed septic system There's no increase in flow and/or change in use proposed • Th a are no variances requested or needed. • e bottom of the proposed leaching facility will Mt be located less than five feet above the tna .mum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using G1S information) .��• �/ B) G.W.Elevation _ +the MAX High G.W. Adjustment DIFFERENCE BETWEEN A and B / 2 SIGNED : / / DATE: (Sketch proposed plan of system on backs. y:health folder:cat A C .�/ .��, 11M{ ' V` N i ��• _:t= TOWN OF BARNSTABLE LOCATION 3a c�� ':ck �y� SEWAGE # -5 37 VII.LAGE lJ N VN►v�5R-� ASSESSOR'S MAP & LOT I INSTALLER'S NAME&PHONE.NO. Rai►N}CzJ `7-7 5-277.- SEPTIC TANK CAPACITY I500 LEACHING FACILITY: (type) �c�vw�(�S" (size) i 2x Z1;k-S•. . F. NO. OF BEDROOMS C � � 0/-r) SyS �Ir1 i 7 BUILDER 0 OWNE C- PERMITDATE. aacG COMPLIANCE DATE: Ili? acoo 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 Feet within 300 feet of leaching facility) Furnished by 4 0 { CO.NBIOX EALTH OF MASSACHI;SETTS _ EXECI;TME OFFICE OF E.NVIRO\NNE\TAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION O\7 nT\'TER STREE7. BOSTON 11iA 0210� 1617,242-550to ,,}- TR MY COL Secreta- ARGEO PAIL CELLtiCC! DAVID B STP-HS Governor Corrmuss:one- SUBSURFACE SEWAGE DISPOSAL SYSTEM OMPECTWN FORM PART A . CERTIFICATION Prop"Address 32 Chadwick Rd. Name of Owiwr r'^r^^Y=n Date of lr.AfionHyanni sport Address of Owner: Name of bispector:(Please Pdn0Wm. E. .Robinson Sr. 1 am a DEP approved s erq inspector to Seetian 15-W of Tide S(310 CMR 15.000) Compaiiykame: Wm. E. Robinson Septic Service MailingAddress: 20 BOX 0 9. Centerville MA Telephone Number: CERTIFICATION STATEMENT 1 certify that 1 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 sew a disposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails i Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty 130)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. NOTES AND COMMENTS - RECEIVED OCT 2 0 2000 '. �,✓ TOWN pFgApNSfi1BIE •,� IIEAI.TN DkPL � reti1Se6 Paprlorn +<: -,.-led o-Rro-c;re Parr, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) NopertyAddress: 32 Chadwick Rd. , W. Hyannisport Date" of 4i��6R r a n INSPECTION SUMMARY. Chselr/ 8, C, o/ D: A. SY PASSES: 1 have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM 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. Indicate as,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. H"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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) 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 pipets). The system will pass inspection if twith approval of the Board of Health): broken pipets)are replaced obstruction is removed `_evJ s2Q eJ�2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 32 Chadwick Rd. , W. Hyannisport Owner: Date of I,uVpj�rOran C. )ublic EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: itions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the health, safety and the environment. 1TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) /FU TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS CTIONING 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 of 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) THER i revise: ev se: Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION lcorninuedl Property Address: 32 Chadwick Rd. , W. Hyannisport owner: Corcoran Date of Inspection: D. SYSTEM FAILS: You must dicate either "Yes" or "No" to each of the following: I ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the faiiure. Yes No Backup of sewage into facility or system component due to an overloaded orclogged 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 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. Any portion of a cesspool or privy is within a Zone I 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. LA SYSTEM FAILS: You must dicate either "Yes' or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public h alth and safety and the environment because one or more of the following conditions exist: Yes 0 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 It of a public water supply well) The owne or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of a Department for further information. rev-se6 5j 2/5b PaRc4ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART 8 CHECKLIST Property Address:32 Chadwick Rd. , W. Hyannisport Owner: � Date of InspVtQJnCoran Check if the following have been done: You must indicate either "Yes- or "No" as to each of the following: Yes i No Pumping information was provided by the owner, occupant, or Board of Health. _ 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. 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 NIA. -41 _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The 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. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] The facility owner land occupants,if differeru from owner) were provided with information on the propermaintananr&-0f SubSurface Disposal Systems. { Page 5 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: 32 Chadwick Rd. , W. Hyannisport O—Cocoran Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow•�9Pd.lbedr om. Number of bedroomsAd_esign): 4vO Number of bedrooms(actual):_ Total DESIGN flow✓✓��®""�� Number of current residents:_0 Garbage grinder lyes or no):_�e7 Laundry Iseparate system) (yes or no)A- -6; If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):X 0 Water meter readings, if available (last two year's usage Igpd): 1999 none Sump Pump (yes or no): 4- 0 1998 1 , 000 ga . Last date of occupancy:— S�mom' CO MERCIALfINDUSTRIAL: Type f establishment: Design slow: gpd 1 Based on 15.203) Basis o design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non•sa tary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last da a of occupancy: OTH Ale' Last Ale of occupancy: GENERAL INFORMATION PUMPING RECORDS and spur , of information: System pumped as part of inspection: (yes or no)— If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components;date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no)AU rev—iseC1 9�2,��c Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddres332 Chadwick Rd. , W. Hyannisport Owner: Cocoran Date of inspection: BUILD' SEWER: (locate o site plan) Depth b ow grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distan a from private water supply well or suction line Dia er Comm nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ _ (locate on site plan) ll Depth below grade: � / Material of construction: t.Eoncrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ ls.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: C� + Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: n Distance from top of scum to top of outlet tee or baffle: r' Distance from bottom of scum to bottom of outlet tee or baffle: L� How dimensions were determined: &4; c comments: (recommendation for pumping, condition of inlet and o e tees or baffles: epth of liquid level in relatiioon{�outlet invert, structural integrity, ev/id�ence of leakage. etc.) /b V-u—i )�� G A/ rb -- IC- I ✓J � y�-�- 1ol'eG b GR E TRAP: flocat on site plan) Depth elow grade:_ Maten I of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimen ions: Scum ickness: Distan a from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co ments: fret mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi nce of leakage. etc.) '_"ev —ced page 7ortl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) +ropenyAddress: 32 Chadwick Rd. , W. Hyannisport Owrw: Corcoran Date of Inspeebon: TIG R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate site plan) Depth bel w grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimensio s: Capacity gallons Design ow: gallons!day Alarm esent Alarm vel: Alarm in working order: Yes_ No_ Date previous pumping: Com ents: (con tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: O Comments: Inote if level and distribution is equal, evidence of solids carryover, a idence of leakage into or out of box, etc.) - � ll PUMP C AMBER:_ (locate o site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comment (note co ition of pump chamber, condition of pumps and appurtenances, etc.) revises 9/2 /98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 32 Chadwick Rd. , W. Hyannisport Owner: Corcoran Date of Inspection: �/J SOIL ABSORPTION SYSTEM(SAS):_✓ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number:_ leaching trenches, number, length: leaching fields. number, dimensions: overflow cesspool, number._ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, d p soil, condition of vegetation, etc �� t S L �— S T6 r L► yr✓A c)!� / 13 CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: / Dimensions of cesspool: Materials of construction. Indication of groundwater: inflow (cesspool must be pumped as part of inspection; jondition s: dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) site plan) of construction: olids: Dimensions: s: dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ",roperty Address 32 Chadwick Rd. , W. Hyannisport owner: Corcoran Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Id revised 5,'2/9� Pige10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM■IISPECTION FORM - PART C SYSTEM INFORMATION(cortt%-dl ropemAddress: 32 Chadwick Rd. , W. Hyannisport Owner: Corcoran Date of Inspeebon: NRCS Report name Soil Type_ Typical depth to groundwater uSGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow Moderate SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater)? Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property. observation hole.basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 6 ` revised 5/21/5E page jiorii