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HomeMy WebLinkAbout0281 PHINNEY'S LANE - Health (2) :281JPHINNEY'S LANE, CENTERVILLE A=230 009 I e � en . UPC 12534 Soi, No.2 1153LOR ` MASTINO8.YN r� o?30-00' / Commonwealth of Massachusetts �,.ij (sp Title 5 Official Inspection Form �"I' a:+ i :•I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Lna Property Address Lisa Devitt Owner Owner's Name -e, information is : required for every Centerville MA 02632 12-7-18 <75 page. City/Town State Zip Code Date of Inspection ' Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information ��„ . /35,3S-' Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR.15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. N Passes 2. Q Conditionally Passes 3. E Needs Further Evaluation by the Local Approving Authority 4. 0 Fails 12-7-18 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form w_� � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 .page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:- . ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent: System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts a Title 5 Official Inspection Form II w., ! i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System'will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ON ❑ ND (Explain below): ❑ obstruction is removed El ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: [� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r� y Title 5 Official Inspection Form w" i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 r a 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system ❑ yst m has a septic tank and SAS and the SAS Is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 18 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form ,.i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in'the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑' ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts f Title 5 Official Inspection Form I�I Yrl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4, 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner i should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 18 i Commonwealth of Massachusetts r� Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is Centerville MA 02632 12-7-18 required for every � page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 12-2018 Date t5ins .doc-rev.7/26/2018 p Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 � Commonwealth of Massachusetts y Title 5 Official Inspection Form 4, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d p Y(gP ) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner--pumped 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w., ,V Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln JJ' Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is Centerville MA 02632 12-7-18 . required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 611 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 10 of 18 c~ Commonwealth of Massachusetts Title 5 Official Inspection Form ? �+iM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W >r' 281 Phinneys Ln Property Address . Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Strum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Y,�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): Good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 •f " Commonwealth of Massachusetts { ,w Title 5 Official Inspection Form -i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 cam' Commonwealth of Massachusetts y; Title 5 Official Inspection Form ��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln J Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator field in good working order with no sign of back-up into d-box or surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinne s Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 1� 3 Title 5 Official Inspection Form w., '-�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately vctck _T ­.V 30 (0: oa - *2 � er � r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i A Z 203 498 758 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent to Street&Number , /0 D Post Office,State,&ZIP Cabe -Ce Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee to Retum Receipt Showing to Whom&Date Delivered a Retum Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ Postmark or Date 0 ILL 07 a j Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carrier(no extra charge). m 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach,and retain the receipt,and mail the article. cc LO ` 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this f receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. li 6. Save this receipt and present it if you make an inquiry, 102595-97-B-0145 r d,PENDER: V •Complete items 1 and/or 2 for additional services. I also wish to receive the a► ■Complete items 3,4a,and 4b. following services(for an d ■Print your name and address on the reverse of this form so that we can return this extra fee): 24 card to you. ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. d ■Wdte'Retum Receipt Requested'on the mailpieoe below the article number. 2. ❑ Restricted Delivery W r� ■The Return Receipt will show to whom the article was delivered and the date a C delivered. Consult postmaster for fee. 0 v 3.Article Addressed to: 4a.Article Number a 2 209 CIV 7S9 E 4b.Service Type u 2�` `{�h P�l� Zane,- ❑ Registered Certified M _aa ❑ Express Mail ❑ Insured S w ( r"� v� ��/�' Q�� Return Receipt for Merchandise ❑ COD C 7.Date of Deliv / Z a p 5.Received By:(Print Name) 8.Addressee's Address(Only if requested and fee is paid) to g 6.Signat e:(A res77n t) m PS Form 3811, December 1994 102595-97-B-0179 Domestic Return Receipt a + UNITED"STATES POSTAL SERVICE First-Class MailPostage&Fees Paid USPS Permit No.G-10 • Print your name, address, and ZIP Code in this box • Public Health Division Town of Barnstable P 0.Box 534 Hyannis.Massachusetts 02601 I OF BAJELN TABLE LOCAlaON StrWAGt3#�' ....._._. VIT:,LA�iE AS ESSOWS "&LQ7' --- -�-- i INSTALLER'S NA14 E&PI4QME NO: �E1'TZC WANK CAP.f�CI'I'Y SUS _� � F �LCI444G�f+AC1'I"X� tag) '' ✓� a 7�Y5 (sine) NO OP'BODROC1lV1S .�...:..�..... IM099 O1k OWAIRk { ITtDA'rE C{ CE 1DA ., .. ,.,. Sepui slice es o:Bgtvieen thot �A�axlmumAtl}pBt�tl:Gk�ouudVV�tec'Cabiet�tic BcritntredfLaa>�hing F�u;ility. .......:.,�. i��1va4 V'Jatr SuAraY1w�ac���.caahi� AciltryIf eaty e�eils exist G adtd ac:wlthtn 7Qp foot of tensfun�f icWty). caa i~ct cy�'Wetlan said X.eact�to�t?ac tiny lw sty-wettuncls:exist svltf�itl�Q(�Eger virleaG inkhG Mae i"uralibid,.tfy T i71i�L s i ALI- .5-i ' el TOWN OF BARNSTABLE 3 1_ tiCA'T'ION � t'`ti N ��FS �•�-2 SEWAGE # — .TLLAGE -�=�L.T e,ry� � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1 6 SEPTIC TANK CAPACITY FN L rDGi T�NGi ze>-1 ��= LEACHING FACILITY: (type) �L(si ) NO.OF BEDROOMS 3 BUILDER OR OWNER -50(-d l PV 47 PERMITDATE: 1 2- '3 G 7 COMPLIANCE DATE: l - ,Z6 L y� Separation Distance Between the: .d 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 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ter" O^ (6+ `- V � 0 TOWN OF BARNSTABLE PCATION �.�� n S SEWAGE # VILLAGE Le. ASSESSOR'S MAP & LOT D INSTAI:LER'S NAME & PHONE NO. Let- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OK UELIC WATE BUILDER OR OWNER S-t�AIV LZ- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No UaI �) �3,q ��� 1e 1 1► ,�o • Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinneys Ln Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water Check cellar 0 Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) El Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist-on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ,, Title 5 Official Inspection Form��r� rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 281 Phinne Property Address Lisa Devitt Owner Owner's Name information is required for every Centerville MA 02632 12-7-18 . page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplicatton for Mi0p gar 6pgtem Con!9trurtion Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. t pA 5 Owner's Name,Address and Tel.No. G `cz-�vi `2 Assessor's Map/Parcel.� vc 01 a 6T6 Installer's Name Address and Tel.No. 06& YDesigner's Name Address and Tel.No. Type of Building: Dwelling No.of Bedrooms GL 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 -3 14 e gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 15 UU 5,� d Type of S.A.S. C L� 11­/-6-T-Y"ti�s Description of Soil Sy = n,}(,l Nature of Repairs or Alterations(Answer when applicable) TtiSK WA ( [`�O 7 L` .ieT✓t-' It ®n /SIC (zYA 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 o place the system in operation until a Certifi- cate of Compliance has been i B Signed Date - U Application Approved by Date Application Disapproved for the following reasons Permit No. 9 7 7 3-3 Date Issued ------------------------------------ THE COMMONWFA1 T" ^= '.prx+°"^+""^>'c+r.. !�...-is"w.•,w r�-.^,ems.r �._.�.., . ._ �..-:.;..._ ..,.: :.— ..- ..,..;..,-..R—.:._,-.-.. -.�,.--...._ ....• _ _ zr.m�* „ ._ ..4w� .... No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: w, '---,PUBVCHEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes TippYication for �Digpogaf *pgtem Construction Permit, R '000 / Application fora Permit to Construct( )Repair(V)Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No.ag.t y Owner's Name,Address and Tel.No. Assessor's Map/Parcel �S Q r'dTV4 i Installer's Name,nAddress,and Tpl. Designer's Name,Address and Tel.No. �I r` Type of Building: Dwelling No.of Bedrooms SL Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 0`c� gallons per day. Calculated daily flow 1 gallons. w Plan Date Number of sheets Revision Date Title ,, . Size of Septic Tank T}hpe�o j�s&s� [ \c_. I tti �L� Cs Description of Soil iN1c t° G . $ 11,v7 r5n Nature of Repairs or Alterations(Answer when applicable)LW Sk 44 1 G7-lA w- 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 pious sion,.oaf Tjtle5 of the Environmental Code and o place the system in operation until a Certif- cate of Compliance has en ' ued.la . of-l4ealtt-- Signed Date Application Approved by Date 1 'I -30 Application Disapproved for the fol owing reasons Permit No. / 7 d $ Date Issued . y - 1 ' THE COMMONWEALTH'OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance /rA` THIS IS TTQ_GER ,that the On- ite Sewage Disposal System Constructed( )Repaired( )Upgraded(►' ) Aban ned( )by 'Q, �.¢ S G of i e has been constructed in accordance with the provisions of Title'5 and the for Disposal System Construction Permit No. T- 7 3' dated Installer Designer The issuance of this permit shall not a construed as a guarantee that the syste will function as designed. Date Q , Inspector No. / / � -------- Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS Migogai *pgtem ongtruction Permit ; Permission is hereby,anted to struct( )Repair( Upgrade( f)Abandon( ) System locate( in hQ -t 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: t d` �'ZS 67 72 Approved by z• I� j -- I 10/9/97 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 ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 7 � h h ��,�� u J11 eets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will p-Q1 be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) 3y o /5; 3 bow SIGNED: DATE: LICENSED SEPTIC 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]. q:health folder:cert Y _ RAMffA,MAW Town of Barnstable Department of Health, Safety,and Environmental Services Public Health Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health Steve Sorota 281 Phinney's Lane Centerville, MA December 2, 1997 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 281 Phinney's Lane, Centerville was inspected on October 26, 1997 by Michael Dedecko, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • Breakout of sewage effluent evident, leaching pit shows "signs of hydraulic failure." You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code,Title 5 within(14)fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty(30)days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. ORDER 0 BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable _ Department of Health, Safety, and Environmental Services ""WWMAWWW" Public Health Division Ohl 367 Main Street, Hyannis MA 02601 Office: 509-790-6265 'norm A.McKean,Rs,CHO FAX: 509-790-6304 Director of Public Health TO: �( � DATE: ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. (lk -1 � 1 The septic system owned by you located at 281 Rwwj5 as inspected 0�' eP by 4��e l L?p Ctcj�o , a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • 2�1Va� Fe7 SrE4O lL (L You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty, (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHt'SETTS EXECUTIVE OFFICE OF ENVIRONME\TM- AFFAIRS ' DEPARTMENT OF ENN-IRONNIE\TA�L PROTECTIQN 0ONE �'1NTER STREET. BOSTO'\. MA G_105 Pi.�t-=9.•-vo1/ W 01�y� S 199 y %17LLIAV F:%VELD �/ ✓ Z�� -'� H�FPlg9�F +O TRUD1 CO)T Govemc• / (P Secretar\ ARGEO PAUL CELLL'CCI ` D.A`'ID B STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9 Commissioner PART A CERTIFICATION q \ Property Address: L [�X\);pt,�g �,(� i 4��i I r Address of Owner: ��z Date of Inspection: 16 u I l "� (If different) Name of Inspector. Q o I E��C iro I am a DEP approved system inspector pursuant to Section 15.340 of Title 3 (310 CMR 13.000) Company Name:'42://cy i14-, c En Pa.,r"A 0"to H 42o 1 Mailing Address: Pep ACDA e 329 t flH 1919a4e.2_ H 111�_ © 2_-4,q Telephone Number: _ r-Se ) �L l:?— (4& Zy CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and tha- the information reported belw,% is true. accurate and complete as of the time of inspec;oo-.. The inspection was performed based on m} training and experience in the proper function and maintenance of on-site sewage disposa. systems. The system: _ Passes _ Conc,t-onaii� Passes Neees Funhe- Eva!uat;on 5� the Local Approving Authority Fa•:s Inspector's Signature: Date: _ ''yI� ��_�Ll_L The 5vsterr Inspector sha" submit a cop,. of this inspection report to the Approving Authority, within thirty (30) days of completing this inspection. If the system is a shared system o- has a design flov. 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. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 61 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 conforming septic tank as approved by the Board of Health. (ra.•aa,iod 04/25/97) Page 1 of 10 DEP on the WOnd Wide WeD htto./iwww magnet state ma.uvoer Printed on Recycied Pacer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (contin.j-d Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Healthi. Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets!. The system will pass inspection if (with approval of the Board of Health): broken pipets) are replaces obstruction is removed 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, safer and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER M WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or pm� is within 50 ieet of a surface water Cesspool or prn- ,s within 50 ieet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet 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 I of a public water supn1v 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 04;25/97) Page 2 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propert,. Address: Owner.S6 g 4T0 Date of Inspection:'� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Y` No Pumping information was provided by the owner, occupant, or Board of Health. V _ None of the s\•stem components have been pumped for at least two weeks and the system has been receiving normal 7j flow rates during that period. large volumes of water have not been introduced into the system recently or as pan of this inspection As built plans have been ob;a:ned and examined. Note if they are not available with N/A. _ The facrlm or 6%elling \+as inspected for signs o`sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site \,.as inspected for signs of breakout. _ All components. excluding the So-[ Aosorption System, have been located on the site. L •, _ The septic tank manholes mere uncovered. opened. and the interior of the septic tank was inspected for condition of baffies or tees. material o construction, dimensions, depth of liquid,_depth of sludge, depth of scum. / —The size and locat,on of the Soil Absorption 5vstem on the site has been determined based on The facdit\ o%%ne• iano occupants. if diperen: from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H _ Determined in the field sr am of the failure criteria related to Pan C is at issue, approximation of distance is unacceotabie (15.302.31 b (revised 04/25/51) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..t PART C SYSTEM INFORMATION Properts Address: �u1 91rutic 1 j Owner: soap A- Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow ,:)634_g p.d.lbedroom for $.A,.S Number of bedrooms A&— Number o'current residents j Garbage g•:;der (yes or no.- Laundry co-•^ected to'system (ves or no`4 Seasonal use tyes or no,.—,—J Water meter readings. if a table (last two 121 year usaee (gpdi: (J Sump Pump Ives or no) Las; dace o`occupancy COMMERCIAL'INDUSTRIAL: Type of establishmen: Design fio%% _�al,ons,,da% Grease trap present Ives or no_ Industna! Taste Holding Tani: oresen: •ves or no 'ion-sanitan waste d-scnargec to the Tice 5 ;ves or no %%ater meter readings if avadabie Las:pave o: o --pa-c. OTHER: Describe Last date of occuoanc• GENERAL INFORMATION PUMPING RECORDS and source of inforrnxion System pumped as par, of ins &ion. (ves or no If yes, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tank,/distribution boxrsoil absorption system A— Single cesspool 1bV{V041 i 4R4 elf Overflow cesspool Prn-)• Shared system (yes or no! (if yes, arach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: , cnVwmk 1 ��11pC^�TI��(fj 1IY1� Sewage odors detected when arriving at the site. (yes or no) (revised 0{/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: FhrNN'lfO Owner: 56 to T/} Date of Inspection: 16 N,� SOIL ABSORPTION SYSTEM (SAS)A5 (locate on site plan, if possible; exca,.ation not required, but may be approximated by non-intrusive methodsi If not determined to be present, explain: Type: leaching pits, number. leaching chambers, number. leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensjo^ . overflow cesspool, number Alternative s\,stem Name of Technology. Comments in to condition of oil, signs of h draulic failure level of po d0g, c d n of vegetation, a .). CESSPOOLS: _ (locate on site plan Number and coniigurat,on Depth-top of liquid to inlet inver, 1 Depth of solids layer 12`I Depth of scum layer. Dimensions of cesspoo! Materials of construction Indication of groun&.%ate 0 \ inflow (cesspool must be pumped as par, of inspection) NU Comments: (no a condition of s i, signs of hxdraulic failure, level of pondi condi vegetation, etc.) CIII 00-Mi lie V PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r.vi.•d 04/25/97) Page a of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION (continued) PropertN Address: j� Ph S N/kq j Ow ner:�0(to 0 Date of Inspection: p 1 zb l q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Uf)1 1 � 2-- ay t (revised 01/75/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C nrt SYSTEM INFORMATION (continued) 1'Proper-h. Address: p�� I7lNyVCY c f Owner: -';6-ebT - Date of Inspection:'`/,,. eY7 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans.on record Observation of Site (Abutting propert), observation hole, basement sump etc.) Determine it from local conditions Check with loca! Board o: neaun Check FEMA Wraps Check pumping records Check local eaca.ators. installers A— Use L 5G5 Data Describe in vou, o�+n v,oros r.o" \o.,; established the High Groundwater Elevation. (Must be completed; CICPQ 401 �f fG 3-?VLks lrevaaed 04;25'5".- page 10 of 10