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HomeMy WebLinkAbout0029 GREEN DUNES DRIVE - Health 29.Green Dunes Drive Centerville P A = 246 164 II I UPC 12543 No..,, 5� 3.3LOR HASTINGS.UN No. Z t)O 3— Z 70 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Mi5p0af �bpgtem Con!Aructi= Vertu Application for a Permit to Construct( )Repair(-✓)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. a,q G(-tk^ b u l e_s t�C Owner's Name,Address and Tel.No. c /Y l' ay((0 Assessor's Map/Parcel W. 14 y A/1/11 s P o 1 b I Russo Q / / Instis N e,Address and Tel.No. Designer's Name,Address and Tel.No. / yo tdr20V, (Su^CUS alb 0S- WLAF8A(n. 2Z 0s), 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 a Nature of Repairs or Alterations(Answer when applicable) 0 D O Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of H th. OF Signed Date 6 f Application Approved by _ Date (O -_ Application Disapproved for the following reasons Y Permit No. 2D03"- zr7a Date Issued —————————————————————————————— — ——�—— r7 `5 i No. 2 V0 3— Z I D Fee THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZippYication for Mizpooar bpgtem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) El Complete System 0 Individual Components Location Address or Lot No. a.C( I C-y Fji n t7 u n eS D�. Owner's Name,Address and Tel.No.D M ay(p`• Assessor's Map/Parcel w. l4 y A n,11 S v� J � U 2P �'1 t�U S SO P �o Inst er's Namlle,Addressf and Tel.No Designer's Name,Address and Tel.No. Lo i— yU Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building N No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow C gallons per day. Calculated daily flow gallons. Plan Date a Number of sheets Revision Date Title r' Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) s OX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed ( Date i Application Approved by .S Date 6 16 Application Disapproved for the following reasons ` Permit No. 200 3" 2r7U Date Issued 1-7 03, �1 t :41 `` -r1 THE COMMONWEALTH OF MASSACHUSETTS G� BARNSTABLE, MASSACHUSETTS \ `r r ,J- (Certificate of (Compliance °X `�� ,a THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( Upgraded( ) Abandoned( )by Go i an Run-/),, s at QLq r ee n 1 i-)no_ S (..J �,,a.� iala d I` has been constructe^in/accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Z603-2 7L\ dated Installer Designer The issuance of this pe it s 11 not be construed as a guarantee that the system ill et• d i Date U-3 Inspector ——————n————————————————————————————————— No. �o 3^2 (19 Fee 5 THE COMMONWEALTH OF MASSACHUSETTS r 6 PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS T)" Mizpogal *p! tem Construction Permit Permission is hereby granted to Construct( )Repair(, I Upgrade( )Abandon( ) System located at r C11 G(et-, 1�/�S Li �� i74n1 sn ow l -a oX raAp A, C 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:Constru tion ust be completed within three years of the date of this pe Date:_ �D �7 b 3 Approved by fr TOWN OF BARNSTABLE LOCATION"09 Greer bu%s SEWAGE # LL VILLAGE ASSESSOR'S MAP & LOT :r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY GAI. LEACHING FACILITY: (type) off' �oX 6' (size) UUb 5AL NO. OF BEDROOMS—�- - BUILDER OR OWNER JOc. be,116 Russ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ng facility) Feet Furnished by c oot For a 6- o � a /a.(v SIA2, -3 a y 3cU Y e.� 30.b COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED JUN 2 6 Z003 TOWN OF BARNSTABLE TITLE 5 HEALTH DEFT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address- 29 Green Dunes Drive �M �N� +, nwzt, MA 02672 Owner's Name: Joe Dello Russo Owner's Address: A h(^ Date of Inspection: June 13, 2003 (� Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Neods Further Evaluation by the Local Approving Authority Fa' s Inspector's Signature: Date: June 18, 2003 The system inspector sh\subit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 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 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Green Dunes Drive , West Hyannisport, MA Owner: Joe Dello Russo Date of Inspection: June 13, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Green Dunes Drive West Hvannisport, AM Owner: Joe Dello Russo Date of Inspection: June 13, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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. 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: 29 Green Dunes Drive West Hyannisport, AM Owner: Joe Dello Russo Date of Inspection: June 13, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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 well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] 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 System: 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 No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 29 Green Dunes Drive West Hyannisport, AM Owner: Joe Dello Russo Date of Inspection: June 13, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 Green Dunes Drive West Hyannisport, MA Owner: Joe Dello Russo Date of Inspection: June 13, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCULANDUSTRIAL Type of establishment: Design flow(based on 310 CUR 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 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAi. INFORMATION Pumping Records Source of information: Pumped on Aug 20102-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system ` Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1977 per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive West Hyannisport, MA Owner: Joe Dello Russo Date of Inspection: June 13, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6" 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive West Hyannisport, MA Owner: Joe Dello Russo Date of Inspection: June 13, 2003 TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was broken down structurally. A new D-box was installed(Permit No. 2003-270). PUMP CHAMBER: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive West Hyannisport, M4 Owner: Joe Dello Russo Date of Inspection: June 13, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): One pit 03)had 3'ofwater on the bottom The scum line was approximately 4'up from the bottom. The bottom to grade was 8'and the cover was 1 S"below grade The other pit 04)had 6"ofwater on the bottom. The bottom to grade was 8'and the cover was 18"below grade There were no signs of failure in either pit. CESSPOOLS: None (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: None (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.): 9 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: 29 Green Dunes Drive West Hvannisport, MA Owner: Joe Dello Russo Date of Inspection: June 13, 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 a-11_we1ls.xithin_100 feet- I.ncate where-public.water_supply enters the-building:- 8 �A A� 0 � A a 3 ab go.b 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive West Hyannisport, MA Owner: Joe Dello Russo Date of Inspection: June 13, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15 +/- feet Please indicate (check) all methods used to determine the high ground water 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 Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 1 S'+/-to ground water at this site. This report has been prepared and the system inspected and passed 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 warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection ► One Winter Street, Boston MA 02108 (617)292-5500 �(�/ /��O G) pl T • COXE C� Secretary ARGEO PAUL CELLUCCI B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 29 Green Dunes Drive, West Hyannisport, MA Name of Owner: Margaret McRae Address of Owner: Same Date of Inspection: November 16, 1999 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, OsterriUe, MA 02655-0049 Map: 246 Telephone Number: (508)862-9400 Lot: 164 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Eva l n By the Local Approving Authority Fails Inspector's Signature: Date: November 19, 1999 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 _ Page Iof11 j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport, MA Owner: Margaret McRae Date of Inspection: November 16, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. 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. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage_backup,or breakout or high static water level observed in the distribution.box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport, MA Owner: Margaret McRae Date of Inspection: November 16, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health safe and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH"AND SAFETY AND THE ENVIRONMENT: r The system has a septic tank and soil-absorption systeiti"(SAS)arid-the'SAS is within 100 feet to a surface water.supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport, MA Owner: Margaret McRae Date of Inspection: November 16, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded,or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped-- Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of:a cesspool or privy is within_a:Zone 1,of a,public.well Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,.attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped Zone H of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 29 Green Dunes Drive, West Hyannisport,'MA Owner: Margaret McRae Date of Inspection: November 16, 1999 Check if the following have been done: You'must indicate either"Yes" or"No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not a4iilable with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions;depth of liquid,depth of sludge;depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 Green Dunes Drive, West Hyannisport, MA. Owner: Margaret McRae Date of Inspection: November 16, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 4 Total DESIGN flow n/a Number of current residents: 1 Garbage grinder(yes or no): Yes Laundry(separate system)(yes or no): No If yes, separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1998-306,0001?als.: 1997-148,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: god(Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on file-per Treatment Plant. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) UA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date_installed(if known),and source of information: 1977-per as built card. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a29 Green Dunes Drive, West Hyannisport,MA Owner: Margaret McRae Date of Inspection: November 16, 1999 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting,evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'6"x 4'10"x S'(1000 gal.) _ Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:- I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How dimensions were determined:, Measuring stick. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) The inlet baffle and outlet tee were present. The liquid level was even with the outlet invert. GREASE TRAP: None (locate 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) _ revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport,.MA, Owner: Margaret McRae Date of Inspection• November 16, 1999 r :•. ;::,: ,; -, ,:.; TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present ,. Alarm level: Alarm in working order: Yes_ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ �•. :: (locate on site plan) Depth of liquid level above outlet invert: -- Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was located but not dug up. There were no signs of failure in the pits. PUMP CHAMBER: None (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.) revised 9/2/98 Page 8of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport, MA Owner: Margaret McRae _.a Date of Inspection: November 16, 1999 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: 2-6'x 6' leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number,dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Pit#4 had 6"of water on the bottom. There were no signs of failure. Pit#3 had 4'of water on the bottom. The bottom of both nits to grade was 8'. CESSPOOLS: None (locate on site plan) -- f• 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(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: None (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.) I revised 9/2/98 Page 9of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport,MA Owner: Margaret McRae Date of Inspection• November 16, 1999 ,,zAAF w Map: 246 Lot. 164 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3A� \A A 3 93 yy Ay- a o to revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Green Dunes Drive, West Hyannisport, MA Owner: Margaret McRae Date of Inspection: November 16, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 15 +/- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ✓ Observed Site(Abutting property,observation hole, basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health , Checked FEMA Maps Checked pumping records Check local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Hand au eyed down to 12'below grade and no water was observed. Using the Barnstable topographic and water contours g g g maps, the maps were showing approximately 15' +/- to groundwater at this site. This report has been prepared and the system inspected and passed 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 warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 ;1 No....... .6°'f... /S.............. THE COMMONWEALTH OF MASSACHUSETTS l � BOA R D F I-1 E L - - .............OF...... .. .... • ApplirFa#ion for Dispoii al Works Toustrnrtinn Vamit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewa Disposal Syst at: Q AIFS'l i I Llo ._. .......:K ........!�/.,1.*`. .................. ....•----...........--------------•-------- ---•--... ....... ..... •------- lion- dress or Lot No. ---'- • -- .. .---- ......• •.............. •......... -------------------•-••---••.. _..................0 .......... Owner Address W � y Installer Address Type of Building Size Lot.- h .............Sq. eSt U Dwelling—No. of Bedrooms........../�............................Expansion Attic ( ) Garbage Grinder Other—Type of Building ------•-•-----------•------- No. of persons ............ Showers (�, — Cafeteria ( ) Otherfixtures ----------------•.-----------------------------------...-------•----------------------. --- --//�- /1�-�------------ W Design Flow..... per person per day. Total daily flow. ...1 !..........................gallons. WSeptic Tank—Liquid capacity.I'FL... allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—N ..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......� Diameter----6.X_k.. Depth Belo ]ml .... ....-_. Total leaching area...... . ft. Z Other Distribution box ( Dosing t k ( D/" ` ��� 2" � 7_ .70- 7 - y� a Percolation Test Results Performed by...... °..._.,lc� ....................................•.... Date.... .1-7.4..__. Test Pit No. L.9 ...____minutes per inch Depth of Test Pit.................... Depth to ground water-__7..._..........._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil... x -•-••-----------------------•----------•••-••••-•-•••-•••-------•••••--•••••••-------•-----•----••------•--•-----•--••------•---•-----••-••-••-•---•-•---•-------••---•-••••---••••--•-•-----•-------••- U Nature of Repairs or Alterations—Answer when applicable................................................................................_.............. ....•-••• -------------------•--------------------••-•-------------•---------••.-•••-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLij 5 of the State Sanitary Code—The undersigned further agrees not to place the yste in operation until a Certificate of Compliance has been issued th2brd of/Iialth.' / ......... --•-••••.......... .... Date Application Approved By.. � .' 7 Date Application Disapproved for the following reasons:--•-----•---•-•---•----------------------•---------•---•---------•----•-----•-•----••-•-•-••--•--•••--....--•--- ..---•---------------•-•------•-•------••-•--•••-----..._.....----•-•-•--•-•••-----------...-•-•-----......-------------------••••-------•-•-•----••-•-•--•••--------•-•-•--••--•----•••••-•-•--•----•--- 3 , 77 Date Permit No............... Issued -----------------•-•-••-•------------ Date No......:....r0 ... Fiz$........`.... ..........._ THE COMMONWEALTH OF MASSACHUSETTS BOARD F• HEA" L/l"; ..-.. OF..... ..........GG!�l^.Y/!... Appliration for Bispoa al Vorkg Tnnitrnrtinn Prrmit Application is hereby made for a Permit to Construct (,� ) or Repair ( ) an Individual Sewage Disposal Sys "at A t 'mil./'.2 LZ. ...—....I.. �....�.' .................... ......•------•--------................----. ..tiondress � or Lot No......... .I .-----•------ -•---.....---•-------------•---•--•-----... .I.... ........................................ .. l�/ /�-�' `�- Owner Address DWI ' ........./ �//= .......... ......... Installer Address Type of Buildin �j Size Lot.Y-.:...._==-Dwelling gNo. of Bedrooms.............!-.._._...._.._....._..._......Expansi` Attic ( ) Garbage Grinderq( )C C) Other—Type of Building ............................ No. of persons....... ............. Showers (,�44 — Cafeteria ( ) Q' Other fixtures .................................. d Design Flow.... - �....................gallons per person per day. Total daily flow.. ...._...A. gal W ® Ions. WSeptic Tank—Liquid"capacity/ .'_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—,N))o. .................... Width......_....._..._.. Total Length.........._......... Total leaching area___-.-.•.___---_-_-_sq. ft. Seepage Pit No-------/----------- Diameter-__ ......... Depth beloyyyy i e�... otal leachingg area........ ft. Z Other Distribution box (�() Dosing tank Grp ' C J_ .?a- 7G. a Percolation Test Results Performed by..... ........./5.•_'_ .............................. Date..._.__. . .....�.(...... Test Pit No. I--- —_--__-_minutes per inch Depth of Test Pit.................... Depth to ground water---y.................. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ l - -- n -- O Description of Soi.12_ t �.......... --------------------------------------------------------- W ----•-------------------------------------------------------------------------•-----------------------------------------------------------••--------•-•----------•------•-••------------•---------••-.-- UNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------------- ----------------------------•------...-•-----------•--------------------------------................-•--•-••-------•••-•-•--•----------------------------•-----•---•...---••-•------------------••-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLi; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenissued by the hoard of health. �� l Signe .. , 1�_��.:.at rC; . ('.1.........7 Application Approved By------ ,�'C-'1��'S..n. vLla�` ••--------------------- :.......G ` e 7 -a---------------- Date Application Disapproved for the following reasons:------•--•------------------------------------------•-----•---•-------------•------------•------..._...---•--... ..----•---------------------•--•-------•--•---•-------•-------•-•--------....•--•----•----------•---...•.•---------------------•------•--------------•-•-•---------------•----•-----•--•--•------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ....... ............OF.. ..... ................ C9rdifirtt#r of Tomph anrr THIS IS TGLCERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by }.: . it_ ...................................�= ----------.._ .......... O _ _ at............................•.... •-�G�!l �•---•- =- Y• -.._._...-I U'- ............... � � ` has been installed in accordance w' the provisions of T ; 5 of T State Sanitary Code as described in the application for Disposal Works Construction Permit No. ____ ....__ __...__. da.ted_...�..�` 7�................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI L FUNCTION SATISFACTORY. DATE---...... 2 7 ... Inspector..•-• !wl THE COMMONWEALTH OF MASSACHUSETTS % BOARD F HEALTH ................0 F,Nft..... . ................................................... 1V Os ............... FEE.L................. DisposatiVifrb ��aa rn uan Fermi ' Permission is treby grante"...... /. ` C/......ice f '7- -------------------------- ------------•---•---•--...---•• to Constr �� Repair` ) an,Indiv'du I'S��rage posal Sy j _ , at No:..... .I ' ��// Z '�. Street �j, as shown on the application fo isposal Works Constructi�Per it No _.._ t- // �'lated.7:-�.`7.7 L �/ =V . • -- _ � � Board of Health DATE--- / ........................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r TOWN OF BAKNSTA3LE LOCATION Greets , uew S 'r SEWAGE # VILLAGE 14 -1nrl1S �20r7- ASSESSOR'S MAP &LOT d4lto (o INSTALLER'S NAME&PHONE NO. (Al. e Uj 1 S SEPTIC TANK CAPACITY C1(ro T Et1CHING FACILITY: (type) )ITS (size) X , NO.OF BEDROOMS BU LDEk OR OWNER MArC-h-eT' Mc, rAe-- PERMIT DATE: �l �I' 11 COMPLIANCE DATE: 23' -2 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) Feet z Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by S_ e_ph C i �13 Al- rya- ►a� f3a- 31'' /Y6- as , (33 y 9 . 3y— 30 c� 3 � y L0,CAT10 � SEWAGE PERMIT NO.. p ,a Z 9 PILLAGE J INSTA LL R19 NAME & ADDRESS B UI'LDE R OR OWNER DATE PERMIT ISSUED _ 1 DATE COMPLIANCE ISSUED �'/ l �3' -7 7 f \ d Peak, y� �9'0/Z''S p r bxs'c,f' T L �9 7Z0 J � f ,p rsA 39.E ` v 1 'L_o T - v M. � 70 J OF add ROBERT 4`G P. d: SUNIXI r n Nd.8420 CER?IFtED PLOT PLAN �19 5�Pr0.✓ Lor 40 GRA-&AI _l>VA Fs Pki✓E ,NE4V .CONSTRUCTION ONLY : � 1�j' N/r/spe, -r TOP-iof • FOUNDAT.ION ,IS-,:.�...„ FEET IN # ABOVE' LOW POINT OF -ADJACENT t,{ �,Fr OAa. j Y SCALE J 4D- +DATE • 71I 77 ' L EV 9 E 81IVfE 111fG I1V 'i'CERTIFY UN CERTIFY'. THE FDD.�7`/JN P9U%�PN t h . . Stt0�ltk ON THIS PtAk IS LOCATED a + $t .TEAEt) ri>wt31$TEREp4*9 QAi . THE CtRf1UN0 a8 %I�t01Cl1TED AND _ N L. W S $U# Y .XO ,. , ,.,�,�',, y CONF�?Rfll .,gip THE . ZONI 4 A r .a Y -�.--.a .�. flF` AItNS ' HE MA i �'12 NIA ar : 20 FT, M//V. hit-------- - CONCRLTE "PYC PI PL I CLEAN �''�N'R M rx-, P/7CN OD, P, l C'DYERS /B"PFR FT. f _ CD✓BR 4"CAS •. ' 2"LAYER ?a /RON f�E /2 SO -CAL . • . . T� . . "o qF If'8 -'�/B" t� :b M/N. P/TGN • ♦ • •f s • ' • • • • s •a WASKB:O S7t7NE "Peril /'T DIST 54P7'/C TANK BOX • a w ♦ ♦ • • • . r . a o t • ♦ ♦ � s . sra � , • • • s r e • /~'iECTI�L' • r WASHED 5740NE KSwZMM c • tt r • • • • • • ♦ r A o . 0 # 0 op • s.. , * • . • s . , • , p •a PRECAST SE.EFA4GE 1Nli&M7 G'LEVAT/ONS s ., • • • s ► • • ♦ sr� o P/7 OR SQL!/V. /NY."T AT Ol//LD/NG 97,y . �C�� cL°'wwULA7JON> INLET .SEPTIC' TANK `��. S F FT.F . L-- F7 VIAM.---- OU74e,,T SEP?'•I C TANK 2b•3-FT. _ /N,LE�`D/STR/BI/TIQN BOX 9 ?K-cr GRDUMD VAF.R TAtSLE .SEC7"<4N O F ; 0dTLE'TD/3TR/BVr10N AOX 9 S.-7 FT ' " a- /NLOtSEEPACUF Oc-17- 5. 3 F T SEWAO& APLSIPOISA A. J"-1'7'&M 7A- el1LAT1GN 3 PC A L E Y4 k + r QIME/Vst o JV• JA R'T. _ DES/SN CRITRR/. ,0/ME%VSION $— F7. NLIMdt,E�R OJT SEDQRoOJ+�S 4 y "•`WO�ti E":G7� SrA�. tl/V✓7r'- _;.: as �.,w�. ,. a:ww. •_ D/L TE�'� r Q GAL.f1�4'� spirA. 1.66 '.F 4 ''E d�' SOIL TE.S7` ,. g�3 7 b' slo's 4L'44CA/ING P1-At PIT ! �6 ,o fT. - .l` e3 ". g fJL 'L (WITNESS D dY P. C.'M vrZIZA / ' 4007-7'OA4 L4"CHIN G PS P/T--7-jr .sq, ITT. ' rl�t l /VV/NCH 70Ti4L 18AGM// 6 IRCG�►'�'14N .�1TE MJ.. DATA O)V /_/c.f'- r�YJ'r" R{��f L�L4CNI/Y6 ARE/ SQ. F 7` / 5!J SO i L f�A-DNS T,6.1 c,, $G, a l�f -A 4-7W r + , tv%Of A/C-> LOT /4© -c7Re--IV uP �E Air✓& ?� •-RC Bf RT ��.� y/s' A11V'/S Pam/ P. � ._ 1-4 ��c .. . _ '. � , • F�,a�I��`�'>6�';E�r/l�?'.B�R/JNCs-CQ7lACG, srf + 7►/1? !►lAIyN ST .. 3 %rD.t4A//v.$-r: ' •e: 5t�puc{�� r JtY.ifN,A►t� f4A0S. S'i!. YARMOt/TX�Mddx ti )4S Ato. 7 7