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HomeMy WebLinkAbout0026 CRANBERRY LANE - Health 26 Cranberry Lane Centerville A = 226 - 115 r' 0 NoP2®1e0R �,� � HASTINGS,MN .__.,. N. C;).c �J Fee C/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye 4plitation for bisposal *pstrm Construction 30ermmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) [:]Complete System °Individual Components Location Address or Lot No. a(0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ro 1 -5 ���j r Installer's Name,Address,and Tel.No.SCif acik4 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (J� A c.10 ' arm, kAoy", -�- t) CeSS�J p'L\ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this BaUdZNealth. Signe Date Application Approved by Date 11 Application Disapproved by Date for the following reasons Permit No. '� )�S ` 2� Date Issued No. C7 I �f _ Fee �C) �• THE COMMONWEALTH OF MASSACHUSETTS Entered.in computer: PUBLIC HEALTH DIVISION--TOWN OF BARNSTABLE, MASSACHUSETTS Ye 4plitation for -isposal 6pstem Construction pertnit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System []ndividual Components Location Address or Lot No a C r cj,(QC! (v L,(,. Owner's Name, ,t Address,and Tel.No. Assessor's Map/Parcel �F 1 r�'v� I M c)L`( _P,r Installer's Name,Address,and Tel.No. SOX aG Designer's Name,Address,and Tel.No. �c �s,�cc,.�.lti �N 3 p\d yc ,(,.o 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �$ 0"10/ G.l rN Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforeesciibed 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 Certificate of Compliance has been issued by this Boa ealth. Signe >� Date Application Approved by ,�! Date Application Disapproved by s Date for the following reasons Permit No. S.015 Date Issued / ------------------------------------------------- ---------------- ���.� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of Compliance THIS IS TO CERTIIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by J C v at Wbe n nstructed in accordance with the provisions of Title 5anand the for Disposal System Construction Permit No.--')C-/S 01 5 dated 7/7/)-5 Installer CO �"C—(,�1�-vim Designer #bedrooms Approved design flow gpd The issuance of thi pe it shall not be construed as a guarantee that the system wi of fiction as desigL i Date Inspector ---------------------------------------------------------------------------------- No. '3�ev 15 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS - Disposal 6pstetn Construction 3oPrtnit Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( System located at �_r r\ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction myst,b�corr�filet d within three years of the date of this it. Date // //� Approved(;by �c � v T04N OF BARNSTABLE LOCATION �� C-(-Q^( P-JrStj U/-UEWAGE#0`®/,S-" a I,,� VILLAGE C-�/`k- V%\`! ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. c,!Frc—A Vl, aCj A (0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) e) NO.OF BEDROOMS CBS's OWNER M e PERMIT DATE: - `71 f S- COMPLIANCE DATE: 7 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within ',".'300 feet of leaching facility) Feet FURNISHED BY .,� Z� C1'a.•�r 1ti1e cl.. c A CA S6eOoL A Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments PropM&S ^it J Owner Owner' Name information is ' 1 /_ � q g 1 required for every l page. City own 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 fort. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector. 7 � key to move youro� cursor-do not � use the return am Insp or key- A 1 ` -- � _ om y - ComppnyAd ress :.__...___..,. Cityltown ---A e 81. /,3I-110 Ztp — 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.T he 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 3 Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Firs f C - ❑ Needs Further`Evaluation by the Local A proving Authority ' NZ� lit s W ors nature Date he system inspector shall submit a copy o this inspection report to the Approving Authority (Board A 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. 15ins•3l19 Title5OfficialInspection Fo :S dace Sewage 113q, Disposal System, 1 of 17 T Commonwealth of Massachusetts Title 5 O.fficial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address` tjd Owner Owner's Name information is -� MAC- page- G� required for every �f i D 6 Cfty/fown State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: Rr 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•3113 Title 5 Official Inspection Forth:Subsurtace Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts kipr Title 5 Official Inspection Form C Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prope dress f Owner Owner Name information is Ce� 19/4 required for every page. City own State Zip Code Date of Inspection B. Certification (cunt.) ❑ 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 breakout 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•3113 Title 6 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 Prop=�Wci5 , Owner Owniep Name information is //�j� D—�� Lt required for every , _�! CJ page. City own state Zip Code Date of Inspection B. Certification (cunt.) 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 El Backup of sewage into facility or system component due to overloaded or K'} clogged SAS or cesspool ❑ 1� 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 %day flow t5ins•3113 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 P�M�5 �14/Ad Owner information is Ow s Na /// /� / Lc��� lJ� �✓7 required for every . page, C /Town State Zip Code Date of Inspection B. Certification (cont.) Yes No. ❑ Required pumping more than 4 times in the last year NOT due to dogged 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. ❑ CK 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 colifonn 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.] ❑ ref The system is a cesspool serving a facility with a design flow of 2000gpd- 1� 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) La a Systems: To be considered a large system the system must s e a facility with a desr flow of 10,000 gpd to 15,000 gpd. For large sy you must indicate either`yes"or'no"to ch of the following, in addition to the questions in Se ' Yes No ❑ ❑ the system n 40 f a surface drinking water supply ❑ ❑ the is within feet of a tnbuta -toa surface drinking water supply ❑ ❑ system is located in a n en sensitive area rim Wellhead Protection Area—IWPA)or a mapped Zone of a public water su well If you h nswered "yes"to any question in Section E the sy is considered a significant threat, or a ered ayes"in Section D above the large system has failed. caner or operator of any large system considered a significant threat under Section E or failed under Se I D shall upgrade the system in accordance with 310 CMR 15,304.The system owner should contact the appropriate regional office of the Department. t5ins-31f 3 Title 5 Offioial Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prope =dress,/,, Owner Own 's Name p /��� 4 aa information is ® - J 1 ' 1 LA required for every page. CWTown 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 2 - ❑ 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? ❑ rat Have large volumes of water been introduced to the system recently or as part of G� this inspection? ❑ El available as built plans of the system obtained and examined? (If they were not available note as WA) ❑ Was the facility or dwelling inspected for signs of sewage back up? �. ❑ Was the:site inspected for signs of break out? G. ❑ 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. rd ❑ Determined in the field (if any of the failure criteria related to Part C is at issue t� approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): � Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Q t5ms•W13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -A V25 Prop Owner Owner's Name t information is required for every page. Cfiy7town 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 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: oa Date CommerciaUlndustrial Flow Conditions: Type of blishment: Design flow(base 310 CMR 15. 3):' Gallons per day(gpd) Basis of design flow(seats/p sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial w e holding tank present? ❑ Yes ❑ No N anitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if,available: t5ins•3A 3 Title 6 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 Prope ress�� Owner OwneXs Name ' information is required for every page. C*/Town State Zip Code Date of Inspection D. System. Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? j( Yes ❑ No If yes,volume pumped: ��o® gallons How was quantity pumped determined? �' Reason for pumping: �IJ Pb6 A-v (/10 ANC, Type of System: ✓�-�✓ ❑ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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 Tithe 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property ddress 2 XX4 _s 10. Owner ownA s Name information is required for every page. City[rown State Zip Code Date of Inspection D. System Information (cunt.) Approximate ee of all components, date installed (if known)and source of information: . Were sewage odors detected when arriving at the site? ❑ Yes ( No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC Elother(explain): QAM&ge Distance from private water supply well or suction line: feet Comments (on condition of joints,venting,evidence of leakage, etc.): Sep " Tank(locate on site plan): Depth belo rade: feet Material of constru n: ❑ concrete tal erglass ❑ polyethylene ❑ other(explain) If tank is met , ist age: ears {s age nfirmed by a Certificate of Compliance? (attach a copy of ce te) ❑ Yes ❑ No ensions: ZSludge depth: t5ins•3113 Tile 5 Official Inspection Forth: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 Prope dress�iC �� d Owner Own s Name information is I /�'L"�P - 31 - 1 4 required for every c.t7ai� v page. City own State Zip Code Date of Inspection D. System Information (cont.) Se 'c Tank (cont) Distance fr top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to of outlet tee or b e Distance from bottom of scum to botto of let tee or baffle How were dimensions determined? Comments(on pumping recom ndations;inlet and tlet tee or baffle condition, structural integrity, liquid levels as related to outI invert, evidence of leakag , etc.): G se Trap (locate on site plan): Depth bel rade: feet Material of constru n; ❑ concrete ❑ me ❑ rglass ❑ polyethylene ❑ other(explain): ,APDimensions: Scum thickness Distance from to scum to top of outlet tee or baffle Distance fr 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property ddress Owner Owr's Nam information is I L' required for every i Y—� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) eemuXents (on pumping recommendations, inlet and outlet tee orb a condition, structural integrity, liquid leve ed to outlet invert, evidence of leakage, etc. 'ght or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth low grade: Material of co ruction: ❑ concrete etal ❑fiberglass ❑ polyethy, ne ❑ other(explain): Dimensions: Capacity: gallons Design Flow: galto per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alaZ'' t switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 Prope Address ��� Owner Wll'TeowAn Cs Nam information is e I ,e(/� i required for every ) ` !� page. State Zip code Date of Inspection D. System Information (cont.) Di ribution Box(if present must be opened) (locate on site plan): Depth o uid level above outlet invert Comments (n if box is level and distribution to outl equal, any evidence of solids carryover, any evidence of leaka into or out of box, etc.};. Pu Chamber(locate on site plan): Pumps in ing order. Yes ❑ No* Alarms in working o r: ❑ Yes ❑ No* Comments (note condition o ump chamber, co ion 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•3113 Tide 5 Official Inspecdop Forth:Subsurtace Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments Props ddress 'C n ��j Owner OwrjWs Name information is a� O Q•3 9 • required for every page. City own state Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): rw I P\ [Sv-id Or '&LdNq Ald A �&-W Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 Depth—top of liquid to inlet invert ,��K Depth of solids layer PU PArj -T�O R-:r4S Depth of scum layer Dimensions of cesspool - Materials of construction Cej,al�16Iog K Indication of groundwater inflow ❑ Yes No t5ins W13 Title 6 Official Inspection Fonn: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 Property Address /� �QvA�r�"v]�Ps P-1 Owner O7TV 's Name information is — � r Q . ?J � ' Li required for every � 'd"i (> page. City)town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Pri Cate on site plan): Materials of con on: Dimensions Depth of solids Comments (note condition signs of hydraulic fa el of ponding,condition of vegetation, etc.): i t5"ms-3M3 Title 5 Official inspection form:Subsurface Sewage D'ieposal systam•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfac/e�Sewage Disposal System Form -Not for Voluntary Assessments ProoertvAddress T. Owner �Ovw�in ' Name (y�Jp�information is �� ' /"PT ®P(I/ O ° 3 ' � Lt required for everypage. Cn State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately C 6zKky i'��( I7 d CES+S�op� � -BI- = A 9- t5ins•3113 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 Prope dress f, MCI IrD Owner 's Name � information is jt—o — '3 required for every page. city own state Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells i Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Boa of Health-explain: K o I Igo ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TsAK7Tr- ,o e,, AiAir G P oum -71 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3f13 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 Ar Prope ddr //{ Owner 0maw information is required for every page. CI ylTown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D,or E checked jol Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposat System-Page 17 of 17