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0115 DONEGAL CIRCLE - Health
115 Donegal Circle Centerville P A = 169 032 r K No. 42101/3 ORA ra Q ESSELT E 10% O O 0 O r NO. FEB. ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Apphration for DijrVitiittl Work.6 Tonstrur#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 1��.. . .............�...v L 11.5_ 1,0V� ram------.......C/�c��=_.. -•• .... ............... Location: 10// Address r of No. ............................................................... owner Address W 11�C1�1 � � La�3 �. `C .... ` �. ...�..-S.' �, L','�' 5 /J. ......... Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-----------------------------------------_-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- -------------------------------------------------•---•--•---- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacitv------------gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area---_..............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...-_.--_.--_---__-_ ((X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-....................... 1:+ ------------------------------------------------------------------------------------------------------• . ---••......... ----------------------- ------- --•' 0 Description of Soil.............................................................................................................................................................................. W V •-•--------------------------------------------------------------------------- ......................................................... ......................................................... W UNature of Repairs or Alterations Answer when applicable.--.A�.._____d�S-.__ }C? a...... At,-�.1?.i .................. i. ......Z`.......S4aYJ-�'•-•-----��......E /-�j i..G'i.........5'�sS n1........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Ce ificate of Compliance has been issued by the board of health. Si ned .. ..._...... o ..... 3� e S Application Approved By - -. ° ._- - --------'-— ---'-' -----...-. ... .... .. ...... .. .................................... -------.....-..ate----------'---- Application Disapproved for the following i ons- --------------------------------------------------------------------------------------------------------------------------------------- - --- ----------------------- --- -- i Permit No. �f' Issued .....' ' ................................ �........ _—___--- Dare----____ J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirtt#ion for Di-nVitiiul Mr1w Towitrur#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ...................(?. ...........................................................SIN L-L l..l., . ........L -N....... -----•---C -=.. ..................................... Location:Address •r of No. Owner Address -• •- Installer —~ Address Type of Building Size Lot............................Sq. feet V Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ._------------------------- No. of persons.......................----- Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... . . d .......................------------------------------ -- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity..........--gallons Length---------------- Width.-.-------__--- Diameter---------------- Depth................ x Disposal Trench— No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------- ----------- Diameter-------------------- Depth below inlet-------------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.........----....... Depth to ground water...................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...---............---... --------------------------------------------------------------------------------•------•------------......................................................... DDescription of Soil........................................................................................................................................................................ ------------- -----------------------------------------------------•. ------------................------......-----------------------.-.....--------------------------------------------------...•-•--• U Nature of Repairs or Alterations Answer when applicable----P.,t3%-------- ff -.. o_�................. L_'. --�.------.snag f�......--�-------.-v� T��G.....-- S'S'S . Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by-the board of health. 3� �� 9 Signed ..---------.._�-.�.. ..-. ........ ............�-fir...... ............ o Application.Approved B ��� ... -DEW ------------- PP PP Y Application Disapproved for the following r asons: . ....................... .. .............. ....... ._............................ ---------------------------- --------------....__.--------- ---- t .--------------------._..- ------------------------.._...-..--------------------------------------- ...... ......... --�. - Date Permit No. ..-- Issued Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE IQTEr#tftrate of (Flom lianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ,p ) by ----�: �C 1C 1 ...__..- -. ------...._----------------------------------------_---------.._-----------.._------. / h,Wk' at .-.......�..� .-._.......... rJ F C.h�t,--------e.�-( ..1��----------------------_C L-nl'�--R V l--�I . .. ......_.........--..... _....._..--------------- has been installed in accordance with the provisions of TITI. The State Environmental Code as described in the application for Disposal Works Construction Permit No. F .�-j.-..�"-..�. -_..... dated ._-.__------.- ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE"COI�STRU AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...... = -------------------- Inspector -------------------- -�... ....... ................. ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.-9 o......... ....•----• FEE......._--............. �iapns�tl orl�� Tua��#rur#ilan "rrmi# Permission is hereby granted...... . . ..------....�AO.K. t°tL-........... ..----------- to Construct ( ) or Repair an Individual Sewage Disposal System at No. \ �c?yJF G!' C? c��6=. �� t- `�ul�� -------------------- --- Street as shown on the application for Disposal Works Construction Perm•�t—No.����-a,/wed_._L`F''�j?,ri�---- ��. ........... a . ••-----•-•-...... E3 Board ofjHealth DATE...........................•--- .. ._.1...--•-•............................. FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS TOWN OF fiARNSTABLE LOCATION //S llnivpe.,AL_. C'ilf- SEWAGE # 9_f--,29Z VILLAGE G� iLt:7_v;//L= ASSESSOR'S MAP & LOT /6� -p3� INSTALLER'S NAME & PHONE NO. I-i iCY Eir eotas°- eo _"7jjuC- SEPTIC TANK CAPACITY© LEACHING FACILITY:(type) P kT (size) j�oo b NO. OF BEDROOMS '3 PRIVATE WELL O PUBLIC WATER BUILDER O O NE =g z-iJ-o LL DATE PERMIT ISSUED: '� k cjJ � p DATE COMPLIANCE ISSUED: , d VARIANCE GRANTED: Yes No ��' ��� �� i/ e;�: � � � s i tI /I �!� �1 /`� Commonwealth of Massachusetts o3a, Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle R Property Address Brown Owner Owner's Name information is - . required for every Centerville` V MA 02632 9/3/19 page. City/Town State Zip Code Date of Inspection q•1 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. A. Inspector Information Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 9/3/19 Inspector ignature 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 toe future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 �. ,z�i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. CitylTown 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 FIND (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 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. City/Town 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 P Commonwealth of Massachusetts lip Title 5 Official Inspection Form 11° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 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 Y2 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. ❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet YP P P Y 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 16,000 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 lF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. City(rown 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? ❑ ® 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 �s (,A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Description: The second leach pit was installed in 1995, the number of bedrooms is not designated on the permit, there was no engineering available either Number of current residents: 1 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3119 page. City/Town 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: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): No d-box Approximate age of all components, date installed (if known)and source of information: Septic tank and leach pit depicted as 3 are original to the home, leach pit 4 1995 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12 feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner formation is owner's Name ' required for every Centerville MA 02632 9/3/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �. lt�: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owners Name information is required for every Centerville MA 02632 9/3/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 �e (t�: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No d-box 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts (e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. Cityrrown 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: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •� 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit depicted as 3 is full at this time, it overflows into leach pit 4, 4 has 20"of effluent in it at this time, sidewalls are clean above the current level, bottom of pit is 9'6" below grade, no indication of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 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 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 LIZ 3 e�6 .3 30 4� o SCN t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ." 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 page. CityTrown 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 round water: 14' p g g 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: n/a Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: no compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: TOPO mapping, the site is at 40'msl and nearby surface water is at 26' You must describe how you established the high ground water elevation: The pit is above groundwater but may have less than a 4' seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Donegal Circle Property Address Brown Owner Owner's Name information is required for every Centerville MA 02632 9/3/19 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: 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 For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L - MMONWEALT OO . H OF MASSACIi�ii JSE'I`PS EXECUTIVE OFFICE OF ENVIRONMENTAL A_FFAIRS ' d DEPARTMENT OF ENVIRONMENTAL pp®TECTJiO1V OW 6 1 TITLE 5 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM PANT A CERTIFICATION Property Address: Owner's Brame: k Owner's Address: �- Ce�► 1/0 Do2 6 ' Date of Inspection• 3—679.- p ' Name Inspector. lease print) qr 0 11, ' Company Name: /I/!/i'p.— AEG Mailing Address: O as Telephone umber S_ c 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 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 n 15.340 of Title 5(310 C R 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Lodi Approving Authority Fails Inspector's Signature: &9r=1Z- Date:_ 2_.2 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 lo,0oo 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 »aaa 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM iNspECnoN pORM PART A CERTIFICATION(continued) Property Address: c O �a CA v- 07-1 v Owner: �(�e�/ � p7 Date of Inspection: 3— _� Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CM R 15.303 or in 310 C-MR 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: T,+la c r.,,._..—__ Page 3 of 11 OFFICIAL INSPECTION FOAM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS'IRM INSP.CCTI01- 4F'ol€M PART A CERTIFICATION(continued) Property Address: Owner: /�MoWpo cv1 Date of Inspection: —02 ae 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 15303(i)(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 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".Mcthod used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from poUation from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less fl=5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS>ESSh [ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTrorf FORM PART A CERTIFICATION(continued) Property Address: �l 194e�o,/ G'„P Owner: Date of Inspection: 3—D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No� _ ��// ackup 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 ogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or �sspool _ _ quid depth in cesspool is less than 6"below invert or available vohnne is less than'/day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped . y 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 f/water supply. y portion of a cesspool or privy is within a Zone 1 of a public well. c �y 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.f This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] /h O (Yes/No)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- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes 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 threa t,o r answere d "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 15304. The system owner should contact the appropriate regional office of the Department. CM Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS_4L SYSTEM INSPEC770N FOR PART B C CHECKLIST Property Address: 1 26oe,�,� Ct r Owner: pr V7 Date of Inspection: < —C2 O Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes � o Pulmmg information was provided by the owner,occupant,or Board of Health Were an of the system components 7 y y trip nts pumped out m the previous two weeks H e 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? �W3s 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 o7a"flWas es or tees,.material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 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: Yes — 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI. SYSTEM INSPFC'TI®N FOPM PART C SYSTEM[INFORMATION Property Address: Owner: Date of Inspection: — B$ RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): o2- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 236 Number of current residents: / Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system�YYes or no):W [if yes separate inspection required] Laundry system inspected(yes r no):/r'' Seasonal use:(yes or no): / Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): A'0 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: rr Was system pumped as part of the inspection(yes or no): — If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPOSYSTEM —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) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of info rnra 'on- Q Were sewage odors detected when arriving at the site(yes or no): Tit)- C Tn encntinn r.'n— cn cin n.- - Page 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTF—M INSPECT_y0N FORM PART C /' SYSTEM INFORMATION(continued) Property Address: /J Q y^ O"GAL Owner: �(i1c W!aki Date of Inspection: —a g-D? BUILDING SEWER(locate on site plan) Depth below grade:.��� Materials of construction: !/cast iron _4� 0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): e SEPTIC TANK:—(lgocate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) J X 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 bot gf outlet tee gr baffle: l How were dimensions determined: 0 2 �� ct//6f--- Comments(on pumping recommendations,inlet and ou et tee or baffle condition,structural integrity,liquid levels a lated to outlet inve evidence o leakage,etc.):GREASE TRAP:AL-*�(-Iocate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART C SYSTEM INFORMATION(continued) Property Address: Owner: UG(✓vnF� _ Date of Inspection: TIGHT or HOLDING TANK: /V (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Az/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J).OV6:.l C�� D�6 3�-- Owner: 6 ti.r Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T yp 6.X C C✓ leaching pits,number:� / �7�{/vj,,�_ 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. : / ' 1 T ohd`✓� Oaf / / 0 r vl h CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:Zoocate on site plan) ) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,simians of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Cjr eve 2✓✓r' /�.� ®�G.3d Owner: c4G yv elh Date of Inspection: 019—t'9 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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_ /JO'-- a AZ-a3 A3� IS3-,3a r�T y r S Page 11 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION r,ORM PART C S STEM INFORMATION(continued.) Property Address: ©tv c9r,/ 6�- Owner• aw 4�11) n � Date of Inspection: SITE EXAM Slope 1W , Surface water�° Q Check cellar y— p Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obta' d from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole 1 0 feet of SAS) Checked with local Board of Health-explain: 5 Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must descr�'be h w you established the high ground water elevatiop: roan c� ,LG� A 0 0 K �S ) w T Town of Barnstable oFt� y�p� do Regulatory Services IAMSM13M ; Thomas F. Geiler,Director �,E16_19.o�rA Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862 4b44 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection.