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0032 FULLER ROAD - Health
32 Fuller Road Centervilie P A = 188 031 i. No. 4210 1/3 ORA Pendaflexo 10 ho A^. f8S TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1500 19 Hummel Drive South Dennis, MA 02660 COMMONWEAU111 OF MASSACHUSE`1"I'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS b DEPARTMENT Oh. jENVIRONMEN'I'Al; PROTECTION TITLE 5 � Y OFFICIAL INSPECTION FORM — NOT.. FOI2 VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Proper( Ad(lress: 32 Fuller Road Centerville,MA '- 16 Owner's Name: Nancy Allen 031 --A Owner's Address: 32 Fuller Road Centerville, MA 02632 t 41 Date of Inspection: June 13,2007 07 Name of Inspector: Troy M. Williams O -Z:I -T) ter, Company Name: Troy Williams Septic Inspections - coMailing Address: 19 Hummel Drive x South Dennis,MA 02660 Telephone Number: (508)385-1300 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 s)stem inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systeni Passes Conditionall\ Passes Needs further Evaluation b) the Local Apptuving Authurn) Fails Inspector's Signature: S , 'L.1 �,,, Date: G //3 /o- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification Is not to be construed as a guarantee of future working condition of system,piping or components. This Inspection represents the conditions of the system on the Date of Inspection noted above. •«"*This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how fire system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 Pape I of l l 'l'age 2 of 1! OPPICIAL lINSPLCTM()N 1?0I1M — N()'J' JiOlt V01,ON`I'AR'Y ASSESSMrNTS SUBSUlIiVACC SI-VvAG'r Ms��as Ys" '><e�NM jNsrrc i'ION FORM C���2`1'�r'Mfi�`M'��N (continued) !'i-apet•ly Addl-ess: 32 Fuller Road Centerville,MA Owner: Nancy Allen Date of Inspection: . June 13,2007 Inspeclion Summary: Check A,h,(,I) t►r h / ALWAYS couiplele all of Seclion 1) A. System Passes: l have not fmild any inliirmalion which indicates Chat apy of the lailure crileria described in 310 CMR 15.303 or in 310 CMR 15.30,1 exist. Any failure criteria not evallialed are indicated below. Conuuenls: 11. System Conditionally I'asscs: One or more system components as described in like "Conditional Pass"section need to 1) placed or: repaired.The system, upon completion of flit replacelliciu or►epair, as approved by the Board o' )Mill, will pass. Answer yes, no or not determined(Y,N,N1�) in the__ lilt the lullowing statements. 'not determined"please explain. Thu septic lank is rnclal and over 20 years old'" ur the septic lank (wile er 1-nelal or not) is structurally unsound, exhibits suhslantial iulilttalion or exlillralion or lank failure is in inenl. System will pass Inspection if)lie existing lank is replaced with a complying septic lank as approver) by 11 Board of health. *A metal septic lank will pass inspection if it is str►tclurally sound, i leaking ant) if a Certificate of Compliance indicating that the lank is less than 20 years ohl is available. ND explain: Observation of sewage backup or hrcak out high static water level in the distribution pox due to broken or obstructed pipe(s)or tine to a broken;sellle"cl or r even dislribulion box.System will pass inspection if(with approval of Botll4 of I jeal(h): hrok-„ pipe(s)are replaced o rnclion is ferhovetl . istribulioll box is leye►ed or replaced ND explain: The sysleni re . Ire d pumping more Chan 4 limes it year Ope to broken or obspucled pipe(s).The system►will pass iuspeclion if Illt approval of lilt Board of t leallh):: bioke►r pipes)art:replacer! oUstructia is rttriovetj Np explaill- Pago 3 of I I 01"11CIA1., 1NS1'LCTION 1()JlM - NOT VOIt VOL1JN'1'A11V ASSI SSMENTS S1J1iS1JI ACl� SI<WACls 00'OSAI. SYS-f-CM INSl'rC11'1ON 11 0121VI I'A A CIERTI1'ICA` ION (continued) 1'roperly Address: 32 Fuller Road Centerville,MA n�nler; Nancy Allen Date of luspectiou: June 13,2007 C. Ii.urther Evaluation is Required 1►y life Board fit llealllf; Conditions exist which require further evaluation by the Board of health in order to determine if file system is failing 10 protect public health, safely or file CnVIio11111e111. 1. Syslen►will pass unless 110ard of health tlele1-!pilfes 11► accordance willt 310 CMII 15303(l)(4) ll►al the system is not 111uclioning In a mallner ryhich w111 prolecl public l►callll,safety and lilt environment: _ Cesspool or privy is within 50 tecl.of a surface water Cesspool or privy is within 50 feel of a bordering vegetated wellanfl or a salt marsh 2. System will fail unless the lloartl of Ilealth(and l'uhlic water Snppli ;if airy) determines that the system is functioning ilk a ir►aullcr 11111i projects file pul►lic heallh,safe) and envi.►ounlenl: _ "Flue system has it septic taok and soil absorption system(S )mill the SAS is:within 100 feet of a surface water supply or,tributary to a suiface walei supply. _ The System has it septic laok and SAS and the S is within a Zone I of it public waler supply. f*he system has if septic lank and SAS and to SAS is within 50 feet of a private water supply well. The system has a septic lank and S and lilt SAS is less Than 100 feel but 50 feet or more from a Ill ivate water supply well". Melhoel •ed let determine dislance "This system passes if the w water analysis, herfmoie l at a PEP ce1-tifed laboratory, for coliform bacteria and volatile olgold compounds inclicates 111al file well is free f)om pol.lulion fiom Thal facility and !be;presence of ainnlun nitrogetl at nilrale nilroOcn is erpaal 10 or less thao 5 ppnl, provided that no other faillaa'e criteria are t berecl. A copy of the analysis must be allached fo this fai111. 3. other: , Page I of,I I ( VIAC:IAI. INSPECTION jlYORNI — NO'lj' lli'()j2 VOM,IWFARY ASSESSMENTS SUBSUM ACV, SL.WikGME' DIISI'()Stklt., S'YS`llI M INSI'EC`I'ION FORM i�A i'J' A ('I�I2`I'MI'ICA"I >!QN (conliuued) 32 Fuller Road 1'ropel ly Address; Centerville,MA Nancy Allen Oweer; June 13,2007 Date of luspectioe; D. Sysicul Vailli t:C'rileria applicable it) ;III sysle►us; You must indicate "yes"or"no" to eacll of the 1i111owilig Ill all inspeclions: Yes No __ ✓ lsackup ol'scwage into facility or system conlporlent title to overloaded or clogged SAS or cesspool _____ lliscliaige ui piluding of effluent to the surface o1'tile gnnulil ur surface waters due to an overloaded or clogged SAS or cesspool Stalic liquid level in the distribution box alluve otlllet inveil due to an overloaded or clogged SAS or cesspool _.___ ✓ Liquid depth in cesspool is less than 6"below invei t of available volun►e is less than %day flow -� ltegililcil pumping plow than 11 tittles in the Iasi year NOT due to clogged or obstructed pipe(s). Number of limes __ ✓ Ally portion of the SAS,cesspool or privy is bcluw high ground wale,-elevation. Any portion of cesspool al privy is wilhiu too feel of a surface wider supply or Iribulary to a surface wale[.supply. Any portion of a ccsspaol of pi ivy is willlLt a Zone I of a public well. Aoy portion of a cesspool ui privy is wilbilt 5p leel ofa piivale wale[supply well. Any poilioo of a cesspool or privy is less Ihall 100 Icel bill greater than 50 ieel from a privale wale•[ supply well Willi nil acceptable wale[quality analysis. ITllis system passes if file well miler analysis, I► I-tarwed at a l e l' eeriificil 1Pil)ok-ato4-y, for colifornl hacleria and volatile til-gauic CO Milo Jill ls indicates (flat lflc well is free f)-aill ItollutiO0 Iron► tflal facility and tilt:prescncc of arnnionia nilrogce and nitralc eitrogcn is ctlual to or less Ibau 5 ppt►►,provided that l►o olber failure criteria are triggered. A copy ill*the analysts mnst be atlached lit this loI IIt.l N� (Yes/Nu)'['hc systeu► fails. l Ilave delennined[flat one qi Inot0 of di above failure criteria exist as dcsclibed in 310 CIvflt 15.363, therclalt; the sysicill fails. The System owner should contact the Boald of, Ilcalih it)deleioline what will be necessary to Cal lecl the failure. I�- f.:y-I;c Systctus; 'I'o be col►sidget) a Itil-ge sysleln the systeuk must serve ;1 facility with it esign $low of 10,060 gild to 15,000 pill. You must indicate either"yes"or"no" lit each ill'like following; (The following criteria apply to large systems in addilion to Ilse clil is above) Yes no _ the syslen is within'100 feel of a surface di inkit water supply the system is within 200 feet ofa tributary , a surface drinking wafer supply __. the sysleln►is located,iu a nitrogeil. se llivc area(lilleiiirl Wellhead holeclion Area-1W1'A)or a mapped Lone 11 of a public water supply I If you leave allsweret)"yes" to ally i ue .talk nil Section E the systeln is considered it significant Jill-eat,or answered "Yes" in Seclioll P ahOve the large stem leas failed 'I'lle owner ol.opelalor of any large syslel considered 4 significant 1llrei►l lintlel.Section F I.failed►ender Seelioll i.)shill( tipgrade (be systeip lit accordance Willi 310 CIv11t 15.301.The sysienl owner sit( tl contact file applollliate,regional office of file peharin?ellf• Page 5 of I 1 OleFICIAL. INSI'I-CTION IeORN_I -NOT 1'OR "VOI.UN`I'ARY ASSI_eSSMLNTS SI1liSURI�ACL SI��YA(yG l)ISI'OSAN, SVS'I'I?M INSPECTION FORM PART A 1'1-optriy Address; 32 Fuller Road Centerville,MA Owner: Nancy Allen halt of Jnsl►ettio,,; June 13,2007 Check if the ti011owiug Dave been done. Yo►l l►plsl indicate"yes"of "no"as to each of the following: Yes No _ l'umpiug iulbinwtion was provided by like owlier, occlipaw, or Board of I lealih Were ally of the system coruporlents purnptll otll in lite previous two weeks'? _ I las the systenk received nornlal flows in Ilse l reviolls two week: period'? ✓ have large volumes of water beerl introduced to the system recently or as earl of this inspection'? Were its built plans of t.be syslCirl oblaillled aollt exalilioed?(If lhey were riot available dote as N/A) _ Was tile facility or dwelling inspected for signs of sewage hack up ? Wits like site inspeclett for Signs o Oieak Wit`?' ✓ _ Were all systeol components, excluding the SAS, located on site'r _✓ Were the septic tank manholes uncovered, opened, and the interior of lilt lank inspected for tilt condition of the baffles of lees, material of construction, dimensions, i ltlr of li aid le Ilit of sludge and depth of scum? _✓ ___ Was the facility owner(a.ml occupants if diffel-tul front owner)provided with inforinatiotl on tilt proper maintenance of subsurface sewage disposal systen►s ? 'I'lle size ant1 location of the Soil Aj,surl►lioll Systerp(SAS)on the site lids been deterriliied based on: Yes ►tO ✓ _ Existing inf oru-lation. l"or example, a plan at lite Baartl of)f eullh. _ Deleppined in the field(if any of the fathtre c►iteria related to fart C is at issue approximalioil ofdislance is tmacceptable.)f310 C.MR 15.302(3)(h)) , Vage 6 of l l 01i 111C1A1� INS1 I C ION CORM — NOT FOR 'VOC,UNI'ARY ASSCSS NTS SUBS1JR AC'Ve SEWAGC DISPOSA1, SYS'1TeM 1NSP C`1'IfON OA M SYS'r'CM IN14 IiMMATWN Vl-operty Addl-ess: 32 Fuller Road Centerville,NIA Owner: Nancy Allen Dale of luspectioll; June 13,2007 VLOW CONDITIONS ItIsSIDIsN'1'IA1. Nmnbcr of bedrooms(design): 3 Nuinber of bedrooms(actual): DESIGN flow basal on 310 CMR 15.203 (for example: I 10 gpil x 11 of bedroom ,3 s): 3'D _ r,_� ,,;1 Numberofcurieul lesideuls: I 0.s_ 6,ift J- (jo1+. Does residence have a gaibagt giiader(yes or no):NQ Is lailiidi y on a separale sewage system(yes ill.uo):N() fit yes separate inspection required) Laundl.Y system inspected(yes(it uo): _n/Lq Seasollal use: (yes of it()): A10 a Walel.meter 1'Calliags, if available(last 2 yelps usage (gpil)): 4/ - 3ZrapJj US OJo ��GLgwS Sump puoq)(yes or at)): _Q . Last(tale ofoccupaucy: COMM L W1AL/INJIUSTRIA1, Type of eslablisbnleol: Design flow(based on 310 CMR I5.263): --_ _-gp(I Basis of design flow(seals/persons/sgli,tle.) -- -- -- Grease trap pieseot(yes of ilo): — — — — Industrial waste bolding lank piesent(yes or no): — Non-sani(ary waste(lischaiged to the`title S systei yes or no): Watel.meter rcadiogs, if available: Last(Litt of occupancy/use: — -- OT.If It (describe):— cl?NI?16Al,IN1 O!UIVIA'J'JON 1'uiupiug 1lccords Source of inPonuali(xl: pip ;;o ol_AN'A I Io Was system plimpe(l as part (St•the inspecliott(yes ol.no): A1u If yes, volume humped: _--gallons - I low was(111111 ily pumped determined? Reason fur piln)ping: _ TY41 (W SYS01 m Septic lAok, (lisiribution box,soil absoylion syslei►► _Single cesspool _Overflow cesspool _Privy . Shared system(yes or"o)(if yes,attach previous inspectiol4 rcconis, if ally) _ lnnovalive/Alternative lecbnology. Allach a copy of ll►c curfent, operation and tliainlenance contract(to be obtained hom system owner) -- fight tank _Allach a copy of the nla' approval Other(describe): Appioximale age of411 components, date installed(if known)al)d source of infuiipalion: 1w6iw14-.4 v(. 1 /Z 19-6 a 0. 6v. I F, Were sewage odors(Jeteclocl wile"arriving al the silt(Yes of 1 0):_dto Page 7 of 1 0111 ICIAI_. INSI'IWFJQN rio ft !< — N()T r_O12 YOVONTARV ASSESSMENTS SUBSURFACE SJ?WACIU: I)JSJ�OSA1, SYS"1'1�IVI INSI�1�C r"Ic�N i�IoliM PA II'V C SYS"TNI INVO(tkr�'jl'(fO1V (contirutetl) 1'roperty Address: 32 Fuller Road Centerville,MA Owner: Nancy Allen t)ule of lospcction: June 13,2007 11UIVOING SEWE It(locate on site plan) Depth below grade:__f$'t ! Materials of construction: _cast jrun Zqo PVC--_other(explain): DiSlall" Ijom private water Supply well or Suction line:—L1L— Conuilcnls(on con(lition ofjoints, venting, evidence of li akage,etc.): SI l"FIC TANIC: V" (locale oil site plan) Depth below grade: 1p" Material of construction: 40concrcte_onelal__ Ijbcrglass ,/polyethylene If lank is tuclal list age: _ is it confirmed by it Cerlircale nfComplialice(yes or no): (attach a copy of cenifii:atc) Dimensions: _ -_-/500_ Sludge depth Distance fi-oin lop of sludge to bottom of oullet lee or ballle: .2 '8'' Scum thichiicss: ---- Dislance boot.top of sciml to top of oullel lee or baffle: Uislance horn botloin of scum to bottom of oullet tee or baffle: IV ;low were dimensions(lclemline►i: prila—/�.s_6,.:1 t•_-- _--_ ___ Coomleols(oil puutping reu►nuueudalit►ns, inlel alul oullet lei or haffle condilion, structural jntegrily, liquid levels as relaled to millet ioverl, evidence of leakage, etc.); Al2.—v✓__:.<<y —(locate on site plan) Depth below grade: Ivlalerial of cpnst}Ilctioll; concrete _metal_fiberglass_polyetltyl e other l)imepsjons: Scum thickness: _— Distance fipn►tt�p Ofscunl to top of 0tillel tee or -- l)istapce fl-Q►#i holtotn of scum to bottom of outlet lee of l' e: Date of last lntlnpitlg• � -- Commel►ts(oil ppmping reconunendations, inlet a oullel lee or baffle contlition,structtirul integrity, ligttiil levels as related to outlet }nycrt, evidence al leakage c.): Page 8 of 1 1 (_Atell'IIOAL.. INSI'LC` ION DORM -- NOT leO U VOIA-IN`I'ARY ASSr?,SSMENTS sL�r svhl�Acl? s WAfiM� J?Msj'0$AM-. sYs`T-N MNsI•rcTMoN r�OhM I'Al2'J' C �YS"ITI M INFORIYIA' 'MON(cortlinued) 1'raperly Aililress: 32 Fuller Road Centerville,MA 0+vner: Nancy Allen !)ate 0 luspeclioll; June 13,2007 '1'JC11'1'or I1O1.J)1NC TANK: (tank must Ue punl4iccl at lime of ins lion)(locate ou.sile plan) Deplll Below gratle: Material ofconstruction: ___coocrete metal__IiUerglas, polyethylene othei(explain): Dimensions--_ __---_--- - — Capacity: Design Clow: _ _ gallons/day Alain piesenl (yes of rlo); Alarm level: --- Alarm in working o cr(yes of lio): _ Date of last pumping: Colllnlents(condition of alarin mud at switches, etc.): 1)1S'l'1211111'J'1ON 11OX; „e (if piesent must be opeilect)(locale on site plait) po I Depth of liquid level above outlet invert: Cnnuneots(note tl hox is level and tlisil ibulion to oullels e(ltlal, any evidence of solids carryover, any evidence of leakage into ui out of lxix, etc-): ' 0-8 vp '.�_s_ �r -�t l_�.N.l -_ h_ wo r L� __� L✓ l� t �/ ITIVJl'CJIANJIJL:l2: —(locale on site titan) 11tllllps III wol king hiller(yes of!lo):_-- Alarms in wgiking order(yes or no): Comnlepls(Hole condition ol`pwnp ellanlber,cnn .toll or l)Lltuhs anti mppuitenauces, etc.): Page 9 of I I j 01TIC1AL IfNSji(e= `(ION I�OWVI NCI!`f fi'011t VOI-.1WFAIty ASSESSWN7'S Stjl1$1J1ZjeAC1: ,WWAC41- I)0'0)81, INSPECTION ISO M PARE C SYSIT-M INVORMA'I'ION (continued) l'rnperly Addl'ess: 32 Fuller Road Centerville,MA Q]voer; Nancy Allen Dale ot.luspection: June 13,2007 Sall, A14SO121'1'10N SYS'1'C NJ (SAS); (loc;llu Oil slle plan,excuy4(i914 Clot retluircd) Il SAS not located explain wily: 1'yl,e ---leaching pits, nun;ber:—- -- leaching chaniUers, number:__ leaching galleries, number: ✓ leaching irenchcs, uumhcr, length: -a_)L�z IWX x leaching fields, number, clirneusions: overflow cesspool, Humber:___ --- ---- — innovative/allernalive system Couumculs(note conclitiou of soil, signs of hydraulic failure, level of pondiug, clamp soil, condition of vegetation,_✓_LL.L��—� T�L�V �.il—S_[=h 4— K —L/!CI ✓ K✓!./� C!'Lc�q ✓►i�_� - �j uG.r.,.-rn�.c.�_ov w ...rr.. ...,� u+� /`+-�. ��/✓..c_ hiu.r v✓ � �L CESSPOOLS: (ccsspuul most be pun]ped as part of iHshectiun)(Iocale n site pla � n) Nondwr and cuuliguraliun:, ------------------------------ Depth-- lop of liquid to inlet inverl: Depth of solids layer. Depth of sccun layer: --_—_— --- Dimensions of cesspool: -- -- Millerials of L'OIIst111L'(lull: _ ludiciilion of grouudwaler inflow(yes or lio): Conu»enls(note condition of soil, signs of (I ulllic 1i ililre, level of pon( ing, conclilioH of vegetation, etc.): 1'121VY: (locale on rile plan) Millerials of construction: --- DlrneosloOs: L)Cptll Ol SOIldS: _ Comments(note condition of soil,signs of hydrae c failure, level o(ponding, condition of vegetation, etc.): Page IQ o f Of VICIAL INSITCTIAN FORM — NQT P(.?R 'OVONTARY ASSI±SSMENTS SUBSt11WACL SLWAG1? I?Isl' S�l�. SYS"I'I'1!'1 I1VS1'1<�C'I'ION FORM .I-�'V C SYS"M'I'IYI INII(V !AII4N (coi�lioued) 32 Fuller Road t'roperly Aildress: Centerville,MA Nancy Allen Owner: June 13,2007 Date a(]nspecliun: sic >jcrl Ol,SEWA(A >�Isl'��sAl.s�rs'hr m Provide a sketch of the sewage disposal syslelp iochlding lies Io at least two permanent reference landmarks or bench► mks. Loewe all wells within 106 feel. Locale where pklhlic water supply enters the building. A I I � O 0 r-_ R - 40, mot. 3 � z z$ ► IU Page I 1 of I 1 OhGICIAL INSI'LC''I'lON 11'0I2IVI — NO'I' 1?OR VOI.UN'1'ARY ASSI?S,SMEN'1S SUBSUR ACI? SPIWAGlie DISPONA14 SYS'ITCM INSPECTION FORM I'Ali'j' C SYS'1TIN/1 INVOI2kjl1'I'ION(coillinued) Properly Address: 32 Fuller Road Centerville,MA Owner: Nancy Allen Dale of Inspection: June 13,2007 SITE EXAM Slope Surliice water Check cellar Shallow wells Estiumated depth to ground walcr .Z►.y Biel Arljuslcd Nigh ground Willer elcvalion I� �� feel Pleiise iudicale(check)all Mr-lbods used to delenuine the high grrrruul wafer elevolion: Obtained Boni system design plans on record - Il checked, dale of design plan reviewed: Observed site(aburliug III operly/obseivalion Bole williin 150 lecl of SAS) ------ Checked Willi local Board ol'Ilealdi-explillll: �o�,} - _ Cliecke(I Willi local excavators, installers- (iillach doctinlenlalion) Accessed t1SGS dalabtisc explain: __-2_Q ' -A, z you mist desc`riibe how you eslablished the high gnonnd ivaler clevaliuu: y y` ----1{n—`-------V_.S.-G.�_--G1 v-...�,_`✓.s���-.r1�[.�cr___-�k,./,.��ye_.I__�..�i:t4vs.-y._ft'+.=t�'le.-'--`�----�-�r-'?a/"-��-'-'-'C--�-�'--- ___red_`_=`-_reed.��/-.LL.I....._Lr1YL.�lV`>__._.I.SL_�._.-..l�S_(ASS..i.4�__�R4L.LY.l�1e[N..�4a1-M .�-�•.17 J. ������_�__ S.51 13•Z� ,�I. h � I — — — — "-pYo'�.t+`'`tip. • — — _ _ 2-1 • r This report has been prepared and the system Inspected as of Ifle dale of Inspection. This report Is not a warranty or guarantee that the systerp wlll funcllorl properly lft the future. There(lave been no warranties or guarantees, either expressed,wrillen of IrppHO, felpUng lq tl1e s)rate►p, the Irrspectloo artd/or this report. II ' s // e° �, TOWN OF BARNSTABLE ''' t LOCATION •� J V t E/ &- i /� SEWAGE # 9 G - 6 ?5� VILLAG A O �t�"Q ASSESSOR'S MAP &LOT �3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �U LEACHING FACILITY: (type) NO.OF BEDROOMS . BUILDER OR OWNER PERMTTDATE: - o (, COMPLIANCE DATE: q Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) j ly0.—Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) XJOJV-4!�-P Feet Furnished by J � �� �' ___._ �i _ ____ � ! G a-g 3 ---�- 1. 7 No. _ Fee �00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprtcation for Mgw6ar *potem Con6truction 3dermit Application for a Permit to Construct( epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lotion AddrLor I�t No. � n L� Owner's Nagie,Addre�,s dje;.l)10. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow —�� � 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 Nature of Repairs or Alterations(Answer when applicable)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 o of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue this d of H Signed DateZ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 03,F / No. Fee THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ' 01ppYication for Miopaal 6pgtem Congtruction Permit Application for a Permit to Construct( pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components w Location Add r s v I,qt� � Owner's Nape, re�o and e I)To IV 5 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 75" Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title r Size of Septic Tank /S-Ga Type of S.A.S. , Description of Soil 7 Nature of Repairs or Alterations(Answer when a plicable) 1� 2 t 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 o Tit1e.5 of the Environmental Code and not toy lace the system in operation until a Certifi- cate of Compliance has been issue this B and of H Signed Date 4L 3t}-<?_6 Application Approved by Date Application Disapproved for the following reasons i ( Permit No. Date Issued ————————————-——-— ——————————————— ——— r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed()()Repaired( )Upgraded ( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.9n L1 9 dated Installer Designer The issuance of this permit shall not be cons d as a guarantee that the system ,'ll.fun�ct' designed. Date 1 Inspector —--——/————————————————————————————————--— No. ((D Logs ! Fee 500c) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi$pogal bpgtem Congtruction Permit { Permission is hereby granted to Construlct,( )Repair( )Upgrade( )Abandon/( ) ` System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: I Z�S� r� Approved by � f - 4 40 .. 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) hereby certify that the application for disposal works construction permit signed by me dated /1 a 3© � �'� , concerning the property located at 3 - Fcez meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: 3 /6 LICENSED SEP TIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j xert ;. . - i l�- �� � lt3 � ,Z�� '� C.��aa CS _. � - �. ._-� ram-- ^- -- -� ., � . _, _.c -- - -` - -.-_ - _ ..___.r _ �� k� k� � G ` JJ TROY WILLIAMS G' - SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 MAP i �� COMMONWEALTH OF MASSACHUSETTS LET CEL ; �� � EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA-ivRS __Z_�,. DEPARTMENT OF ENVIRONMENTAL PROTECTION Y TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Propert% Address: 32 Fuller Road Centerville,MA Owner's Name: Brian&Kathleen Smith -- Owner's Address: 32 Fuller Road Centerville,MA 02632 ov Date of Inspection: December 1,2003 2C'�3 f Name of Inspector: Troy M.Williams v DE(' 0 2. Company Name: Troy Williams Septic Inspections 1O�'tii Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 011560 (508)385-1300 CERTIFICATION STATEMENT I 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance.of on site sewage disposal systems. 1 am'a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svctem- ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �5�,,,, '� :�O_' _ _ Date: / 2 /t /0 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This Inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the saute or different conditions of use. Title 5 Inspection Form 6/15/2000 page I of It 'Page 2ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 Inspection Summary: Check A,B,C,D or E/A WAYS complete all of section D A. System Passes: I have not found any information which indicates that anv of the failure criteria described in 310 CZAR 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 re ced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of alth,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. If' of determined"please explain. The septic tank is metal and over 20 years old" or the septic tank(whet r metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is im merit. System will pass inspection if the existing tank:is replaced with a complying septic tank as approved by t oard of Health. •A metal septic tank will pass inspection if it is structurally sound, 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 ou high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box.System will pass inspection if(with approval of Hoard of Health): bro n pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The syste quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspectio, '.(with approval of the Board of Health): broken pipes)are replaced . obstruction is removed ND explain: 2, ; •Page 3 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 C. Further Evaluation is Required by the Board of Healtb: 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#that the system is not functioning in a manner which will protect public health,safety and the en •'ronment: 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 m sh 2. System will fail unless the Board of Health(and Public Wate upplier,if any)determines that the system is functioning in a manner that protects the public ben ,safety and environment: _ The system has a septic tank and soil absorption s em(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water ply. — The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply. The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. _ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well**: ethod used to determine distance **This system passes ' he well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volat' organic compounds indicates that the well is free from pollution from that facility and the presence o monia nitrogen and,nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crit a are triggered:A copy of the analysis must be attached to this form. 3. Other: 3 -Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: 32 Fuller Road Centerville,MA Owner: Brian&Kathleen Smith Date of Inspection: December 1,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ,L 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 .. N!A Liquid depth in cesspool is less than 6"below invert or available volume is less than',day flow �[ Required pumping more than 4 times in the last year Ij!_Ldue to clogged or obstructed pipe(s).Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ M-4 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/q Any portion of a cesspool or privy is within a Zone 1 of a public well. dLA Any portion of a cesspool or privy is within 50 feet of a private water supply well. a.�(i g 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 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) No (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 desi flow of 10,000 gpd to 15,000 gpo. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteri ove) yes no the system is within 400 feet of a surface drinkin Ater supply the system is within 200 feet of a tribu o a surface drinking water supply the system is located in a nitroge nsitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water sup well If you have ansvrercd"yes"to _ question in Section E the system is considered a significant threat,or answered "yes"lei $ctlQt# .+sb4ve the „ ge system has failed.The owner or operator of any lar$4 system considered a si f�tt It S o or fled under ectloq D sha l,upgr de the system tq#ccardance with 310 CMR 1 S e t old Jtopal office of the Oeparttnent. 1~m Q s3 .la contact thg appropriate re 4 f. Page 5 of l l OFFICIAL INSPECTION.FORM—NOT FAR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No V _ f::;aping information was provided by the owner, occupant,or Board of I lealth ✓ 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) V _ Was the facility or dwelling inspected for signs of sewage back up v _ 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 &bm 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 no ✓ _ 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)) , 5 >i Page 6 of 1 I OFFICIAL INSPECTION..FORM-NOT FQR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART J SYSTEM INFORMATION Property Address: 32 Fuller Road Owner: Centerville,MA Date of inspection: Brian&Kathleen Smith December 1,2001;'LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):c_ DESIGN flow based on 310 CMR 15.203(for example: I I gpd x#of bedrooms): 3 u Number of current residents: `/ - ---1— N` t Does residence have a garbage grinder(yes or no):Alb Is laundn on a separate sewage system (yes or no):—Alp [if yes separate inspection required) Laundry system inspected(yes or no): N/A Seasonal use:(yes or no):_A& Water meter readings,if available(last 2 years usage(gpd)): p 2 = Sump pump(yes or no): ,vo Last date of occupancy: O<<,,e a. COMM ERCIAL/INDUSTRIA L Type of establishment: Design flow(based on 310 CMR 15.203): —gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 syste yes or no):_ Water meter readings, if available: 7Last date of occupancy/use: - OTHER(describe): 10, Pumping Records GENERAL INFORMATION Source of information: P��„_ 2 y,., ,,r:,� Was system pumped as part of the inspecUo(yes or no):_/o If yes,volume pumped: gallons--Now was quantity pumped determined? Reason for pumping: T 'f E OF S�'STEM 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) _Innovatjve/Altemative 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):. proximate age of all components.date installed(if known)and source of information: Wee;sgwagr odors dot;cted when arriving at the site(yes or no): yo E H K 'Page 7ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 BUILDING SEWER(locate on site plan) Depth below grade: 16"+ Materials of construction: _cast iron _,/40 PVC_other(explain): Distance fron.pri%ate water supply well or suction line: lyt o Comments(on condition of joiints,venting,evidence of leakage,etc.): l"I u S�.< I ho C t,..�ul 7"1�v .� .�-✓ n N C In SEPTIC TANK: ✓(locate on site plan) Depth below grade: I " 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) Dimensions: G Iv 'x S ` /So o Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: e? ' Scum thickness: •S' Distance from top of scum to top of outlet tee or baffle: C_ Distance from bottom of scum to bottom of outlet tee or baffle: iy How were dimensions determined: a: •b..:t+./1 Jrt.&— . Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): P✓L h < �..,.f d✓ - * 'f L C s w Gr��Lc� i h. w a vp k .�+ O r�.c c r. /Y O c i.K_c�.L f' f�4 L 6✓ w.u S .[ ..✓c� s TO J K.� /"v"+u,r. v f -Irk ti k'W o v I.A �I C7 i't w.J J.._ 5 ✓Lwf—� ��J je �h ��K T GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_poly ylene_other (explain): Dimensions: Scull thickness: Distance froth top of scam to top of outlet tee or baffle: Distance frgtn bottom of scum to bottom of outlet to r baffle: Dato of last pttmpiag: Co ttistlts(pn pumping recommendations,' and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of le ge,etc.): . 7 Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 TIGHT or HOLDING TANK: (tank must be pumped at time of pection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberg s_polyethylene other(explain): Dimensions: Capacity: gallons Design Floe: gallons/day Alarm present(yes or no): Alarm level: Alarm in work' order(yes or no): Date of last pumping: Comments(condition of alarm float switches,etc.): Pal L��, I DISYI RIB6TION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: I ea-1 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.): Ul6 Ws —r4 l e+J t/ cti...A '.&, W o.%l1. v k 2—_Alt. c.✓: A c r c i a_� L,— c k ✓ u r4 � LA C—.aA,ry 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,conditioZpumpsnd appurtenances,etc.): ti -pap 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why.. Type leaching pits.number:_ leaching chambers,number: leaching galleries,number: leaching.trenches,number, length: 'k yb 'k Z ' 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.): 0 1 wa S S 'k� do vi+✓{ /��o �i,; c� c o toe,�6 f rw S L. '/L.w !J S-/- w ti,/.t_ J�.�,� r,c S CA- 1 Vf f t c ,h s.i S / S hot ci. 5 ✓u i p/"<�— o Y �./ v , U WJiLf:tis �.a..�: f\'� �,3 of �c.� � �1. ti,o / ����.� f O✓ S CESSPOOLS: (cesspool must be pumped as part of inspection)(loca 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#roundwater inflow(yes or no Comments(note condition of soil,signs ydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimcnsions: Depth of;o1jo: Cott1(nen. 4(i>tpt 'condition of soil,signs of hydraul ilure,level of ponding,condition of vegetation,etc.): �; i Page 10 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Fuller Road Centerville,MA Owner: Brian&Kathleen Smith Date of Inspection: December 1,2003 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. A Q4 �LLK Poly , I Soa y-�,,. t 1 O O Poly - 0,-i30k ya , � 2s 51 ' 6 I b 10 Page 1 I of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Fuller Road Owner: Centerville,MA Date of Inspection: Brian&Kathleen Smith December 1,2003 SITE EXAM Slope Surface water ✓ Check cellar ✓ Shallow wells Estimated depth to ground water feet Adjusted high ground water elevation /Z 6 feet Please indicate(check)all methods used to determine the high ground Hater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Ilealth-explain: , ^ ,, 9 6Bo µ• Checked with local excavators, installers-(attach documen=tation) Accessed USGS database-explain: v s c.s /t,, 1 UMW=O S•7 You must describe how you established the high ground water elevation: S.7 '�•+� -- 6 , h �t h.f � 5,,...�A w c��-�.i (-.i,v(. G U.q �. ��1 s r`r,--...r,,•i f2• 1 �9- i , This report has been prepared and the system inspected as of the date of inspection. This report is not a warranty or guarantee that the system will function properly In the future. There have been no warrantles'or guarantees,either expressed,written or Implied,relating to the system,the Inspection and/or this report. 11