HomeMy WebLinkAbout0242 SKUNKNET ROAD - Health 242 SKUNKNET RD., CENTERVILLE
A =
/ J
No. sd / Fee 75
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plitation for -Disposal *pstrm ConstCULtion i3ermit
Application for a Permit to Construct( ) Repaix Upgrade( ) Abandon( ) ❑Complete System P4ndividual Components
Location Address or Lot No.2 %::�X �j�yy `,y��T� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel p/'f!
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms /- No.
Size sq.ft. Garbage Grinder( )
Other Type of Building of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow pro ' ed gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank E� Ae o§' fa®C CW Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) lrz;f
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He
Signed a Date
1 Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. — Date Issued
No. I ` / Fee / -5
�t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplicatlon for Disposal Opstem Construction 'permit r
Application for a Permit to Construct( ) Repai Upgrade( ) Abandon( ) El Complete System dividual Components
Location Address or Lot No. �.C(j�yr�-�y�`j Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Size sq.ft. Garbage Grinder( )
Other Type of Building G'F No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow prov' ed gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ./oo O 6-�4G Type of S.A.S. C ,Q 4X
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) C/�• ��.�%��r "'�� i ��"�Ti��C A
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system'in {
I
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Hea h, j
7Signed . Date / I. j
Application Approved by Date l�3 1
72
Application Disapproved by Date
for the following reasons
--.Permit No. l7 i Date Issued
-------- ------------------------------- --------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
J BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by S:r2.0W ./4&;OEU� St �l�` -0 A-4-
at �aT .r' a� "iY�T Q�'j has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No�7—� dated �`
InstalleA_�10A_9 Lcs-�acr`y Designer
#bedrooms Approved design flow gpd
The issu `ce of this permit shall not becoonstrued as a guarantee that the system will functi'onas_dbsign`ee
Date 4 I I�7 I )t--J Inspector, ^=�.„ J
--------------- ----------------------------------- -------------------- -----------------------------------
No.,— Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 1pstem Construction permit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at aG ,�®� � l/j✓( h'� !/y G ��
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this pe it.
Date ((7 ! h Approved by
� _
Commonwealth of Massachusetts
W Title 5 Official Inspection Form tuf
o Subsurface Sewage Disposal System Form Not for Voluntary Assess
me
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
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.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
v�I Company Name
4 Glacier Path
Company Address
Fn�x
East Sandwich MA 02537
City/Town State Zip Code
508-833-2177 S1287
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. 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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector'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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
nk 242 k S u net Roa
d
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The information provided in this report represents the conditions noted only for June 16, 2017 at 1 PM.
The information contained within this report does not guarantee the operation of the system beyond
the inspection date.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is Centerville MA 02632 June 16 2017
required for every ,
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
= W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Skunknet Road
M
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is
required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 '/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) 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 D.
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
El ❑ 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.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears.usa e d Yes
9 ( Y 9 (gp ))�
Detail:
2015; 19,000 gallons and 2016; 10,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow based on 310 CMR 15.203
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
Was system pumped as part of the inspection? ❑ Yes ® 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate
ate age of all components, date installed if known and r pp 9 P ( ) source of information:
Compliance issued 10/22/1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: . NA
feet
Comments on condition of joints venting, evidence of leakage, etc.):
( joints, 9, 9 )
Septic Tank(locate on site plan):
Depth below grade: 12"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: Typical 1000 gallon
Sludge depth:
2"
t5ins.doc-rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? Scour 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.):
effluent level with outlet invert. No indication of leakage. Tee's in place
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level with outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
New H-20 distribution box. 21 inches below grade. riser within 6 inches.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
3 chambers 21 inches below grade. Chambers empty.
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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is Centerville MA 02632 June 16, 2017
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® 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:
Abutters soil logs in the area.
® Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Soil logs on file with the Barnstable Health Department indicating groundwater depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M e' 242 Skunknet Road
Property Address
Randall and Rosalie Serena
Owner Owner's Name
information is required for every Centerville MA 02632 June 16, 2017
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
t iJJVJJ,.II�t--„-Lunt ..al,., Page 1 of 2
r.
t TOWN OF BARNST LE
ZH ONE/t, .5 KGB Z�.Ge �� SEWAGE p 7 C�
GE 1 ASSESSOR'S MAP Bt LOVE,-4B�0�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �i�d
LEACHING FACILITY:(type) Z
{
(size)
NO.OF BEDROOMS_________ .
BUILDER OR OWNER
PERMIT DATE:,/0 COMPLIANCE DATE:/0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching ility Feet
Private Water Supply Well and Leaching Facility (1f any we exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands xist
within 300 feet of eaching facility) Feet
Furnished'by /�! �L i9 fj e�/rCev
i
1�Rat�t
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=171014&seq=1 6/13/2017
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
J` CERTIFICATION
Property Address: 242 Skunknet Road.
Centerville -�
Owner's Name
Ran��—&moo sali� S_P*-ena
Owner's Address:
Date of Inspection:
Name of Inspector:(please print) W i 1 I i am R_ •Rob' nson Sr. C� _
Company Name: William E. Robinson Septic Service 4 ,
Mailing Address: P O Box 10.89 q
Centerville, MA
Telephone Number: ( 508) 775-8776 = M
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 pursuan7tose ion 15340 orTitle 5(310 CMR 15.000). The system:es
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: e�l Z, Date: /0'
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatih 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 approxing
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: 242 Skunknet Road
Centerville
Owner: Randy & Ros lie Serena
Date of Inspection: - 4 5--
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: `
(a A s
B. System Conditionally Passes:
One r 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 exfrltration or tank failure is imminent.System will pass inspection if the
existing tank is re laced with a complying septic tank as approved by the Board of Health.
'A metal septic 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:
Observati of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Boar, of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
system required pumping more than 4 tames a year due to broken or obstmcted pipe(s).The system will
pass in ection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
7
Page 3 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 242 Skunknet Road
Centerville
Owner: Rand & .Rosalie arena
Date of Inspection::/O— —0 6
C.` Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation b the Board of Health in order to dete
rmine ermine if the system
is fa'ling 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
Z. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
systei it 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
s rface water supply or tributary to a surface water supply.
1 .
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 fronl 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
tie presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. O her:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 242 Skunknet Road
enterville
Owner: Randy & Rosalie Serena
Date of Inspection: f .G S�
D. Sy tem Failure Criteria applicable to all systems:
You mu t indicate yes"or"no"to each of the following for all inspections:
Yes N
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%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
Iwater supply.
Any portion of a cesspool or privy is within a Zone 1 of a.public well.
I 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 f et 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 volatilyrgatiic 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.1
(Yes/No)The system fails.1 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.
Large Systems:
T'be considered a large system the system must sen•e a facility with a design now of 10,000 gpd to 15,000
9RRd•
Ybu must indicate either"yes'or"no"to each of the following:
(Tito following criteria apply to large systems in addition to the criteria above)
ycl 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 11 of a public water supply well
If ou have answered"yes"to any question in Section E Lite system is crosidered a significant threat,or answered
es"in Section D above the large system has fatted.The wAmet or operator of fury large system considered a
s gnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
S1304.The system o%%-ner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 242..Skunknet Road
Centerville
Owner: Randy & Rosalie Serena
Date of Inspection:
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
LI/Wcre any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
_. W 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)
ie/_ Was the facility or dwelling inspected for signs of sewage back up?
i/' 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)J
5
Page 6 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 242 Skunknet Road
Centerville
Owner: Randy & Rosalie Serener
Date of Inspection:„/ - 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x ll of bedrooms):
Number of current residents:-'--161 ri
Does residence have a garbage grinder(yes or no). All
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required)
Laundry system inspected(yes r no) _�'
Seasonal use:(yes or no): jb
Water meter readings,if ava lable(last 2 years usage(gpd)): 2004 - 2 7,000
Sump pump(yes or no): ® 2003 - 17,000
Last date of occupancy: f
COMMECIAIANDUSTRIAL
Type of e� blishment:
Design fl w(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease ap present(yes or no):_
IndusVial waste holding tank present(yes or no):_
Non- anrtary waste discharged to the Title 5 system(yes or no):—
Wa r meter readings,if available:
t date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records s
Source of information: L % ! l Canes �'� -!5
Was system pumped as part of the inspection(yes or no): A
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP 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/Altcmative 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):
00
Approximate age of all components date installed(if known)and source of informatioq:
Were sewage odors detected when arriving at the site(yes or no): A'
6
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Address: 242 Skunknet Road
en ervi e
Owner: Randy & Rosa ie erena
Date of Inspection:
BUILD G SEWER(locate on site plan)
Dcpd clow grade:
Mat ials of construction:_cast iron _40 PVC_other(explain):
Dis ncc front private water supply well or suction lute:
Co imenis(on condition of jousts,venting,evidence of leakage,eic.):
SEPTIC TANK:`(locate on site plan)
Depth below grade: J
Material of construction: �/concrete metal fiberglass�,olyedrylene
_odicr(explain) _ —
If tank is metal list age:_ Is age confnnned•by a Certificate of Conipliarnce(yes or no):—(attach a copy of
certificate) �e-� I
Dimensions: G
Sludge depth:
Distance from top of sludge to bottom of owlet Ice or baffle: /
Scum thickness: C) L
Distance from top of scum to top of outlet ice or baffle: /I
Distance from bottom of scum to bottom ohoutlet ncc or battle:
I low were dimensions determined: 6 Ye%,*— C C, ✓ t,`K-5
Comments(on pumping recommendations,inlet and outlet Ice or baffle condition structural intc it � liquid levels
as related to outlet invert,evidence of leak e,etc.): , _ y }' q
r s rs-0 q a .b w..�'�> �/r /ham 1�4<
GREASE TRAP:_(locate on site plan)
Dcpthtkn
grade:_Matecons ction:_concrete metal fiberglass polyethylen:__other
(expl — —Dime :Scumn ss:Distant top of scum to top of outlet ncc or baffle:
Distant bottom of scum to bottom of outlet Ice or battle:
Date pumping:Conu (on pumping recommendations,inlet and outlet ice or baffle conditio:, structural iniegri►y, liquid ICvcls
as rel outlet invert,evidence of leakage,etc.):
7
,age 8ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOWI-IATION(continued)
Property Address: 242 Skunknet Road
Centerville
Owntr: Randy & Rosalie Serena
Date of lospectloo: -4-0 S—
TIGIIT HOLDING TANK: (tuck must be purnped at time of inspection)(locate on site plan)
Depth low grade:
Materi I of construction:—concrete_rectal_fiberglass�rolyethylene other(explaul):
Uirne sioms:
Capa ity: gallons
Desi n Flow. gallons/day
Al t present(yes or no):
Al level: Alarm in working order(yes or no):—
Dat of last pumping:
Co nents(condition of alarm and float switches,etc.):
DISTIUBUTION BOX: 1/ (if present must be opcncd)(locate on site plan)
Depth of liquid level above outlet invcr:
Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,ctc.): fz
PUMP C AMBER: (locate on site plan)
Pumps'n working order(yes or no):
Alarn in working order(yes or no): —
Con feels(note condition of pump chamber,cundition of pumps and al)purtcnanccs,ctc.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Skunknet Road
Centervi e
Owner: Randy & Rosalie Serena
Date of Inspection: /,'42—(,-6
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,ezcavation*not required)
If SAS not located explain why:
Type/
leaching pits,number:_ 77
leaching chambers,number: J
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.):
CESSPOOL (cesspool must be pumped as part of inspection)(locate on site plan)
Number an configuration:
Depth—t of liquid to inlet invert:
Depth of olids layer:
Depth o scum layer:
Dimen wns of cesspool:
Materials of construction:
Indi tion of groundwater inflow(yes or no):
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: locate on site plan)
Materials of construction:
Dimensio
Depth of lids:
Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Skunknet Road
Centerville
Owner:Randy & Rosalie Serena
Date of Inspection: %` ^�,'0
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
0 .
A o
3 �
N O
10
Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 242 Skunknet Road
Centerville
Owner. Randy & Rosalie Serena
Date of Inspection: Irr,
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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 I50 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must desc J'be how yo established th igh ground water elevation:
.�07 7C1
11
.. ... ... ._._.. _. _ ,� ___: ..i ,• _: ;.mow ..r.
TABI.TOWN OF BARNSE
v
LC�CATION SEWAGE# 3'
VILLAGE ����-i- y1/`ASSESSOR'S MAP,& LOT 1,°,I!
INSTALLER'S NAME&PHONE NO. 2e !r '7 ,4 t
SEPTIC TANK CAPACITY `-
LEACHING FACILITY: (type) J" 9 z 1- y~rt(size): 3'
NO.OF BEDROOMS
BUILDER OR OWNER Cm .`..c.E
-PERMTTDATE: COMPLIANCE,DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to'the Bottom of/weexuis�t
lity Feet a
• Private Water Supply Welland Leaching Facility (If aon site orl.within 200 feet of leaching facility) Feet
Edgeof Wetland and Leaching Facility-(If any wetland
within 300 fee/t,�of�eaching facility Feet
Furnished by �'�`O* «/�"�A�''
, d
r 1� YZb
G1
moo. 79 Fee$50 /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0[ppYication for Mi5pogal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
�1�c io ddres or Lo N O ner's N e,Address and Tel.No.
WunYnett 0Rd.. , Centerville onno�y
Assessor'sMap/Parcel I / L 151 Katherine Rd, Centerville
Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No.
Wm. E. Robinson geptic Service
P 0 Box 1089, Centerville
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
i Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) Title 5 leach system.
D-box and 3 chambers , stonepacked w/64' stone all around..
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.Bogd of Health. If
Signed Date !7— �—
Application Approved by 2�cf_ 9 Date
Application Disapproved for the following reasons
Permit No. 7 F Date Issued �S=
CFO. Fee $50 _
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
. Yes
j
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYtcatton for ;Dt!gpogar *pztem ConMiuctton VernY tom_
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components
do O onennayy Address and Tel.No.idMAL Md. , Centerville o
Assessor's Map/Parcel _ L 151 Katherine Rd.. , Centerville
installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W . E. Robinson 6eptic Service
r 9 0 Box 1089, Centerville
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 Sand
t
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system.
D-box and 3 chambers, stonepacked w/ 4' stone all around..
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 thi Bo of Health.
Signed Date D-
Application Approved by Date /a
Application Disapproved for the following reasons
Permit No. 7 Y Date Issued fir-
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
Connoly BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CNRI ghat htOn-sins to e�age Digos�e�st vice Constructed( )Repaired ( X)Upgraded( )
Abandoned( )by WWtmr. K E 1'
at 242 S kunknet Rd,. . Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. w 7 7 dated G
Installer Wm. E. R ob ins on S r. Designer
The issuance of this permit shall not be constr ed as a guarantee that the 11 function amide One-
Date Inspec r
No. / / � --------------------------
7� —Fee �7,'�_
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Connoly wt5pogar *p5tem Congtructton Perron
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 242 Kkunknet Rd . , Centerville
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: Constructs n must be completed within three years of the date of this t.
Date: / �/' /// Approved by
v• 1/6199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
Ilk
y CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, William E . Rob ins on,S,zhereby certify that the application for disposal works
construction permit signed by me dated ,16 , concerning the
property located at 242 Skunknet Rd,, Centerville meets all of the
following criteria:
Th failed system is connected to a residential dwelling only. There are no commercial or business
es associated with the dwelling.
• The oil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
m sere are no wetlands within 100 feet of the proposed septic system
a1 he a are no private wells within 150 feet of the proposed septic system
• ere is no increase in flow and/or change in use proposed
• here are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
• if the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) —
B) G.W. Elevation +the MAX. High G.W. Adjustment ._
L —
DIFFERENCE BETWEEN A and B _
SIGNED : I c DATE: U S
[Sketch proposed plan of system on back].
q:health folder:cen
i
TOWN OF B_ARNST LE
LOCATION � e
SEWAGE #
VILLAGE t=L- i ASSESSOR'S MAP & LOT 1,10/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY L0tr—a
LEACHING FACILITY: (type) 5— Sr- �" �-�� (size) '? r �2,
NO.OF BEDROOMS v.
BUILDER OR OWNER
PERMTTDATE: /0 —Z S" j COMPLIANCE DATE: 16
Separation Distance Between the: F
Maximum Adjusted Groundwater Table to the Bottom of Leaching cility Feet
Private Water Supply Welland Leaching Facility (If any we exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands xist
within 300 feet of 'eaching facility) Feet
Furnished by
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CO Ni%20\-WEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRO\-ME.,\TAL AFFAIRS
DEPARTMENT OF FsmoNMENTAL PROTECTION
ONE R'I\TER STREET.BOSTON M.A 021OF t617 i 292-550u
TRUDI CORE
Secreta-y
ARGEO PAUL CELLUCCI DAVID B STRL'IiS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property AddressCe- 7tz, i ,,&�-/ Name of Owner 0 A--eG�B
q Address of Owner:jam` Qf �y •� r
Date of Inspection:%� IA"�
Name of Inspector:(Please Print)Wm. E. Robinson S r.
I am a DEP approved system!inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinson Nptic Service
Mailing Address: PO Box 0 9, Centerville . MA
Telephone Number:
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposel`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 ohd experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
4" Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: y L Date: 141-y2-2--57
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
D�G 3ABLE
1999
To"Mi RNST
&TH
r w
DEPT
revised 9/2/98 page Iorll
N
' � • .+,•.rori nn Qervr:r,i Pannr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CE TIFICATION(continued)
"roperty Address:
Owner: 40C
Date of Inspection:
INSPECTION SUMMARY: Check/ C,-or D:
A. SYS 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. S TEM CONDITIONALLY PASSES:
e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon
c pletion 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 pipels). 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
CERrRR�FICATION Icorrtinued)
sProperty Address:
Owner: 0/? C�0 O
Date of InspLion: 16_ A_A
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, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303't1)(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 surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FU ONING 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 of 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 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).
OTHER "
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Ico►rtinued)
PropertyaAddress:
owner:,pr. e"",-70 A
Date of Inspection:14 oa 2 ¢r
D. SYSTEM:FAILS:
You rnustindicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d termination 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 112 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 I 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
colifoim bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARC E SYSTEM FAILS:
You must ndicate either "Yes" or "No" to each of the following:
he following criteria apply to large systems in addition to the criteria above:
he 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
ealth and safety and the environment because one or more of the following conditions exist:
Yes o
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)
The owner r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of th Department for further information.
revised 9/2/98 Page 4of11
3 •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: 0/t
Date of Inspection: p
Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following:
Ye 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 available 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 condition 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.
1/ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
-41 _ The facility owner(and occupants,if differeni from owner) were provided with information on the propermaintenaarAk-0f
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
I ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Iroperty Address:
Owner:
Date of Inspection:,/
FLOW CONDITIONS
RESIDENTIAL:,
Design flow: g.p.d./bedroom.
Number of bedroom (design):� Number of bedrooms(actual):
1
Total DESIGN flow �0
Number of current residents:
Garbage grinder(yes or no): A!D-O
Laundry(separate system) Iyes or no):40, If yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):>t- O /�
Water meter readings,if available(last two year's usage(gpd): /y 99 tee (j��
Sump Pump(yes or no)-,At) ' `/� —7—�L
Last date of occupancy: r4/, /" 7 Q 1 �6� 0 V U y��.
COMMERCIAL/INDUSTRIAL:
Type of tablishment:
Design fl qpd ( Based on 15.203)
Baiis of d sign flow
Grease tra present:(yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-senita y waste discharged to the Title 5 system: (yes or no)_
Water met r readings,if available:
Last date df oc pancy:
OTHER:► scribe)
Last date f occupancy:
GENERAL INFORMATION
PUMPING RECORDS a�ource of information:
s/
System pumped as part of inspection: (yes or no)1j,,J
If yes, volume pumped: ��--- -C)' gallons
Reason for pumping: YZ
TYPE 51 O YSTEM
Septic tankldistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other p
APPROXIMATE AGE of all components, date installed(if known)and source of information:
o
Se 0ors detected when arriving at the site: (yes or no)/
revised 9/2/9E Page 6(of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinued)
'raperty Address:
Owner:
Date of Inspection: /
S ING SEWER:
ILoc eon site plan)
J
low grade:_
of construction: cast iron 40 PVC other(explain)
from private water supply well or suction line
r
ts:(condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
• � t
Depth below grade:LO
Material of construction:let'oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Wage confirmed by Certificate of Compliance_(Yes/No)
Dimensions: _
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_® t I
Distance from top of scum to top of outlet tee or baffle:_ r,
Distance from bottom of scum to bottom of outlet tee or baffle: �1
How dimensions were determined: ( C✓�► 1l a.1�
;omments:
(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.) -A I Tw , < n Y,i /n., to * ! v
ALS 1 �O" �1— �_ Y+ A,ter ki e
GR E TRAP:
(locate n site plan)
Depth b low grade:_
Material f construction:_concrete metal_Fiberglass _Polyethylene_otherlexplain)
Dimensio s:
Scum thi kness:
Distance am top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of ast pumping:
-Comme ts:
(recom ndation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidenc of leakage,etc.)
revised 9/2/98 Page 7oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
}� SYSTEM INFORMATION(continued)
Aropeety Address:
Owner:
Date of Inspection:
TI HT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
floc to on site plan)
Dept below grade:_
Meter I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimen ions: +
Capaci y: gallons
Design flow: gallons/day
Alarm resent
Alarm evel: Alarm in working order:Yes_ No_
Deltaf previous pumping:
Com ents:
Icon tion of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:I
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evoencce of soli s carryover, evidence of leakage into or out of box, etc.)
PUMP CH MBER:_
(locate on ite plan)
Pumps in orking order:(Yes or No)
Alarms in orking order(Yes or No)
Comment :
(note co dition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: sZ-1 .2
Owner: P�- ��no y
Date of Inspection: /a 4!
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:_
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 hM raulic ailurg, level of pondin , damp soil,condition of vegetation, etc.)
.� � Tb n, i` i►%a G •mil .L� �i y:�.d ✓t 3 � Cl� 17a �c.
CESSPOOLS:_
(locate on site.pian)
L
Number and configuration:
Depth-top of liquid to inlet inver .
Depth of solids layer: (�
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection}
Comm nts:
Inote c dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate oi i site plan)
Material of construction: Dimensions:
Depth o solids:
Comme ts:
(note c ndition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2/78 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
avIN SYSTEM INFORMATION(continued)
Noperty Address:
Jwner:,o,�Z— 3,E'� ell
Jate of Inspection: /0
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)
`_
AYZd�- 1
�e
revised 9/2/98 Page 10of 11
y-� 7-10 TOWN OF BARNSTABLE 1
LOCATION L �� �� SEWAGE # %— 130t(6
lnl ..�t
jVTI.LAGE CS.L,�;�2�v� `\ ASSESSOR'S MAP & LOT
+ INSTALLER'S NAME & PHONE NO. -4L":?L\` \
SEPTIC TANK CAPACITY
®LEACHING FACILITY:(type) (size) 1000 �
Q.
O NO. OF BEDROOMS PRIVATE WELL ORd B�WA
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:L
VARIANCE GRANTED: Yes No
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Iconrtinued)
roperty Address: ��
Owner: 17,— JH�'t7'
Date of Inspection:
/G`o7a-9e!
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
I
Estimated Depth to Groundwater 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
Checked local excavators,installers
Used USGS Data
Describe how yo esta ed the High Groundwater Elevation. (Must be completed)
elwxs
revised 9/2/96 Page 11of11