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0279 SKUNKNET ROAD - Health
279 Skunknet Road Centerville F A = 170 256 Commonwealth of Massachusetts ar(P w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 279 Skunknet Rd C Property Address Ma Jeff&Courtney Harris Owner Owner's Name Q7 information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown State Zip Code Date of Inspection V1 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 filling out forms A. General Information ( 7- on the computer, v use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name VQ V 74 Beldan Ln. ICI Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 �� 11/15/2016 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown 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: ® 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: The dwelling located at 279 skunknet Rd is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 3 3050 Infiltrators. The system was found to be in proper working condition at the time of inspection. 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-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is Centerville Ma 02632 11/15/2016 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown 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 '/Z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Citylrown 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 ❑ ❑ 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-3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Citylrown 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts 02 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. CityTrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 years usage(gpd)): Detail: 2015= 182,000 total =499 gpd 2014 = 150,000 total =411 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currrent Date 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-3113 Tide 6 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 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown 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: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments y` 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 5/21/09 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 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: 1000 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M � 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 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 3 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" 11 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? opened covers, took measurements 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 needs to be cleaned soon and again every 2 years for proper maintenance.Water level was at outlet invert, tank was structurally sound 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owners Name information is required for every Centerville Ma 02632 11/15/2016 page. Citylrown 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.): l 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is Centerville Ma 02632 11/15/2016 required for every page. City(rown 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 0 11 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.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown 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.): s.a.s. consists of 3 3050 Infiltrators in a 29'x12'x2'trench. No signs of past hydraulic overloading, vegetation was normal, soil was dry. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owners Name information is Centerville Ma 02632 11/15/2016 required for every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Cityrrown 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 IL T3 13 0 A2_ 3 _ QZ' 26 Pr3 yl G3 3 L 716 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , a 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Citylrown 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 279 Skunknet Rd Property Address Jeff&Courtney Harris Owner Owner's Name information is required for every Centerville Ma 02632 11/15/2016 page. Citylrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 o 0 _MEN m � delivery M o Postage $ of O O Certified Fee L - 0 Return Receipt Fee v S POSU L (Endorsement Required) Me, 2 O � � ResMcted Delivery Fee A (Endorsement Required) a� Total Postage&Fees $ 4ogZ0 Ln nt o ---------------------------- --------- 61 Apt.No.;• or PO Box No. _..- d cny,ware,ziPM �ti 063� Certified Mail Provides.n A mailing receipt (esianay)ZOOZ aunt 013E wood Sd a A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ® Certified Mail may ONLY be combined with First-Class Maile o0riority Maile. s Certified Mail is not available foc any class of international mail. e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. ■For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. if a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. Town of Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 16, 2007 Mr. Kerry Mahar 279 Skunknet Road Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 279 Skunknet Road, Centerville, MA,was last inspected on November 12th 2004 b Mark Poselli a certified inspector y for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System was in hydraulic failure Our records indicate that the necessary repairs and upgrades were not done in the two(2) years given you at the time of the Health Departments order, (December lst, 2004). You were asked to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacements of septic system component(s). This plan was to be submitted to the Town of Barnstable Public Health Division Office (regulatory Services) within ninety (90) days of receipt of that letter. If you can provide a compliance certificate showing that this work was done; so that we may update our records we would be grateful; if not you have 60 days from the date of this letter 7/16/07 to bring the system into compliance. ..j.. ?`.. .il:..f t (.z; e. ,_•! :. _ ';i _ . -,,.'t .J. '' 'tom t " Any person who shall fail to comply shall be fined not less than $10.00 nor more than $500.00. Each day's failure to comply with an order shall constitute a separate violation. BARNSTABLE HEALTH DEP TMENT om s A. McKean,R.S., C.H.O. Agent of the Board of Health �P`OFTNE ro Town of Barnstable Public Health Division o�pSP%' •eN+sc�slE F 200 Main Street � ` � Hyannis,MA 02601 � ® PITNEY BOWES .7005 1160 0000 _0191 3400 02 1A $ 05"210 • 0004606238 JUL16 2007 • MAILED FROM ZIP CODE 02601 Mr. Kerry Mahar 279 Skunknet Road Centerville, 1""" ^^r" X 0*2'9 N7E 1. 4061 Ds 07/21/07 FORWARD TIME E XR RTN TO :MEND MAI-JAR MARSTONS MLS MA VZ640-6574 RETURN TO SENDER - '•� t��b—��'�►�►�ca� lll,,,,,i,I,11„Il,,,,,,II,I, III,,,II,,,,,l,lll,,,ll,,,,l,l,l -- oDst W Zo S65zOt idlaoea wnlaa a1lsawoa b00Z/GEn�gea'L L8S wJO�Sd; ;z -- 1 !S .(legs/ao/Alas W04 Je{suaJJ) 0 0 fi E 2 6'C 0 0000 0 9'1'C S 0 0 Z - JegwnN eIoIVV T j seA❑ (eed a4xg)tau0A11ea PalolAlsaa T -a'0'0❑ IpIN peansul❑ eslpus4aialN Jo;id1wea wniebl❑ paJ9416ea❑ i IjeW smdx3❑ IIEW POI!IJ-13❑ Z£9Z0 VW ed�tleolAJaS •e 4 p1?OU 13uTm'4S 6LZ i ON❑ :moleq sseJppe fJOAllap Jalua'S3A 11 :oi PeSseippV elolliv 'l saA❑ L l wall WQ41uaJaglp sswppe AJOAllep sl .o 1 •sllwJed aosds 11 luoJ;e4l uo Jo 'eoeldpw ayl;o)loeq eyl of pJeo slyl yosl}y ■ AaAllea to elea .D (aweN paluud)Aq PaAlaoaa •g nog(ol pJso ayl uJnlaJ use am lsyl os aessaJppy❑ asJanaJ eyl uo ssaapps pus ewsu JnoA luud ■ _i 1u86y❑ X -peJlsap sl/GeA1Iea palolJlsa»dI b wal! aJnleuslg b aleldwoo osly•£pus"Z'L swell eleldwoo ■ • • • SIHI • • • r ti r_ r Town of Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 16, 2007 Mr. Kerry Mahar 279 Skunknet Road Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 279 Skunknet Road, Centerville,MA,was last inspected on November 12th, 2004,by Mark Poselli, a certified inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System was in hydraulic failure Our records indicate that the necessary repairs and upgrades were not done in the two(2)years given you at the time of the Health Departments order, (December ft,2004). You were asked to hire a professional engineer or registered sanitarian to prepare a plan of proposed replacements of septic system component(s). This plan was to be submitted to the Town of Barnstable Public Health Division Office(.regulatory Services) within ninety (90) days of receipt of that letter. If you can provide a compliance certificate showing that this work was done; so that we may update our records we would be grateful; if not you have 60 days from the date of this letter 7/16/07 to bring the system into compliance. ce l Any person who shall fail to comply shall be fined not less than $10.00 nor more th,qn $500.00. Each day's failure to comply with an order shall constitute a separate violation. BARNSTABLE HEALTH DEPA TMENT . C om s A. McKean,R.S., C.H.O. Agent of the Board of Health YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. r � DATE: �(' B ) I Fill in please: � � m APPLICANT'S YOUR NAME/S: Co v,t- BUSINESS YOUR HOME ADDRESS: 'a-1c1 k-un K�e�F Sub to 2)I 8S 3-7 GZ,h+e y'v1 110- M A 00 (v 5 TELEPHONE # Home Telephone Number NAME OF CORPORATION. NAME OFsNEW BUSINESS SeA p►�SS .:Sfiud O S TYPE OF BUSINESS �2.w�f rU Qes s'Q ! IS THIS A HOME OCCUPATIONS YES NO ""� "�.r. MAP/PARCEL NUMBER ��0 �2 � (Assessing) ADDRESS;OF BUSINES.S� G .qr : f When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. Al. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has been med of the per. ityr equirem that pertain to this type of business. / Cf,f -Au-thorized Signatur ** COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has bn info e o the licensing requirements that pertain to this type of business. thoriz ,d Signat re** COMMENTS: oF� Town of Barnstable P# f,� 5Y2- Departiment of Regulatory Services BARNSTABL : Public Health Division Date 1_112,tXcl MAM �A 16 9. �e$ 200 Main Street,Hyannis MA 02601 Date Scheduled 3 G G- I Time Fee Pd. U� Soil Suitability Assessment for Sewage isposal Performed By: S7&-P1f6k—) /4_+y+�S , PE Witnessed By: G v AJ LOCATION & GENERAL INFORMATION Location Address Owner's Name 43 C-3...k'i_rvC\V_ Address Assessor's Map/Parcel: ?a�25(o Engineer's Name 'Jil— vvak NEW CONSTRUCTION REPAIR v Telephone# Land Use "D6,j_�,-D A--C_ Slopes(%a) --- Surface Stones tiL', Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well _ ft Drainage Way ft Property Line /2 l- ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) r NJ Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: �'�� Weeping f7om Pit Pace Estimated Seasonal High Groundwater DETERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: AIV tiC__ v- Depth Observed standing in obs.hole: in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level .. Adj,factor', Adj.Groundwater Uvel PERCOLATION TEST bate Time Lam: Observation Hole# ,// Time at 9" Depth of Perc �7 t Time at 6" Start Pre-soak Time @ b-` a _ Time(9"-6") ' End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:X.SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Bole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o sistenc %Gravel) DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.% A z2 I- S /4>7'.4- s/� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o si to c Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Comisten y.%0MY01) Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in alt areas observed throughout the area proposed for the soil absorption system? VC--S If not, what is the depth of naturally occurring pervious material? .__w___ Certification I certify that ol 1 f (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training, peruse and experience described in M CMR 15.017. Signature Date � d� Q:\.SEFTIC\PERCFORM.DOC TOWN OF BARNSTABLE LOCATION � SEWAGE# �r -VILLAGE e;Q jUe- ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. -�:)c Y SEPTIC TANK CAPACITY (F t � QcC >C- LEACHINGFACILITY:(type) a0 #30,: 9 (size) W X NO.OF BEDROOMS OWNER C t glJ-C,- PERMIT DATE: C) COMPLIANCE DATE: _S/a 1 Ia 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility L G� feet Private Water Supply Well and Leaching,Facility(if any wells exist on site or within 200 feet of leaching facility) r kyj feet Edge of Wetland and L-aching Facility(if any wetlands exist within 300 feet of leaching:facility). e,,& Fkkfeet FURNISHED BY r `v i Q A 'I � 3S A :?:: - Aq �� a No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migonl 6pgtem Cowaruction Perron Application for a Permit to Construct( ) Repair(.Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. (A R Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address and Tel.No. � l o��p� Designer's Name,Address and Tel.No. S Cp C V �� 5 ,(C 1 �I .!� (nn'\\ 5 C Type of Building: (� Dwelling No. of Bedrooms Lot Size 0 sq. ft. Garbage GrindeWa Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 11 Design Flow(min.required)33 QN gpd Design flow provided p gpd Plan Date Ste ' 1 hn Number of sheets Revision Date Title Size of Septic Tank �'�C� l�C,�Q CTc,\ Type of S.A.S. _?b,!�U 1^ �CVkS Description of Soil c Nature of Repairs or Alterations(Answer when applicable) SR,C*rU2 C roW W W X 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 Health. igned Date Application Approved Date Application Disapproved by: Date for the following reasons Permit No. ^ Date Issued ` � Fee �C! No. Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYfcatfon for Mfgpogal * gtem Congtructfon Permit Application for a Permit to Construct( ) Repair(4Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. a �Vhl nV�( 1`J Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. C�� 5�j �b� Designer's Name,Address and Tel.No. 5 CZ,kt IC7-t.•V1- J l o v c.►,,� re- �S t`� 1 G 3C �I 7 Type of Building: Dwelling No.of Bedrooms :Lot Size p sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures , Design Flow(min.required) �� gpd Design flow provided gpd Yf Plan Date �� � ' (�� Number of sheets Revision Date Title Size of Septic Tank w 0 (T�.\ .. Type of S.A.S. losm Z^ (4�,S `) Description of Soil p Nature of Repairs or Alterations(Answer when applicable) `-,'j f 3p S-(1. C.r��� �� 'w X 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 Health. 1 igned Date pCi Application Approved by Date , T51- 16471 Application Disapproved by: Date for the following reasons Permit No. ^ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (V ) Upgraded ( ) Abandoned( )by 5t_p1\T�N//��...� at d 7� S�Ly^sA,n,t_A 0—d C nj ��� has been construct/ed inn accordance with the provisions of Title 5 and the for isposal System Construction Permit No r .r..�l t5 da d Installer �y �( C!`/� Designer SrC 9 GG.{�� � #bedrooms Approved design flow(\ gpd The issuance of this ermit shall not be construed as a guarantee that the system win,") !qn Is design e Date 2 11 10 Inspector �;,/ —.— No.'(�.r' �f ---------------------- Fee THE COMMONWEALTH OF MASSACHUSETTS l✓ PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS o 1wfgpogaf 16p5tem Cgngtruction 30ermit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at `�7 S _-NV-s IAA.-C\l 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 conditio/ Provided: Construction musVe c mpleted within three years of the date of this pe Date �p Approved by I Y 1 Y TRANS. NO.: CITY/TOWN: APPLICANT: 5C—z, '- ar• �.'-- �� ADDRESS: DESIGN FLOW: 330 gpd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 / CMR 15.220(4)(u)] a/ Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for ✓ components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for / upgrades]- if not, a variance is required [310 CMR 15.412(4)] ✓ Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required and provided) soil absorption system(required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR / 15.220(4)(h) and(i)] V Location and date of percolation tests (performed at proper / elevation?) [310 CMR 15.220(4)(i)] t/ Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and.310 CMR 15.220(4)(n)] Address 279 Svc. .�� .�-J Z?`3�/7y Sheet 1 of 7 N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case / of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR / 15.220(4)(m)] (if water line cross see 310 CMR 15.21l(1)[1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] V Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? 1310 CMR 15.103(4)] V Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep (unless Local Upgrade Approval or LUA requested) 310 CMR 15.405 pP q ) [ (1(b)] Address � �/7o Sheet 2 of 7 N/A OK NO $t f7uf Nz'. Size OK? [31oCNM 15.223(l)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR ✓ 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid / depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9"must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade = one port for systems<1000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR / 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and(3)] "U"pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address 2-7 70 Sheet 3 of 7 i N/A OK NO xg .. BT7ILDING SEsUWERNDOTHEtPI`PING .f �x � ,yam y, . Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line(when water and ✓ sewer cross, see 310 CMR 15.21l(1)[1]) Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / [ 310 CMR 15.222(6)] V Proper itch on all runs? .005 within gravity-distributed t p P ( � y drenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base[310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] IX Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd);waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working--design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address 077 47� Sheet 4 of 7 N/A OK NO N SOI'L'AB8OT2PTTO SYS TEIVIS a : x,z_<',h.: +z.- F a•^ a �»arfi3�� .�."r.': w '`.d"7 �«+':. l �u'�tn'.�>'sY"�'�.2'�.a,..�,:» Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or / >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] GALLERTES,PITS;CIAlBERS310 CMRS'253 Chambers and Gal. in trench configuration supplied withinlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) 1310 CMR 15.253(2)]. Aggregate 1' minimum- 4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] <TTZENCHES 31z0e 1mv �� w;.;8? � x me R a . Width 2'minimum 3' maximum [310 CMR 15.251(1)(b)] 100 feet- maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 25l(1)(d)] Situated along contours [310 CMR 15.251(2)] 4— Breakout OK? [310 CMR 15.211(1)[41 and Guidance Document] -W, BEDSAS�(Maimumsieofsbedorfel�;5000gpc} � � minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(01 Bottom area used in calculations only[310 CMR 15.252(2)(1)] Address Z?g/�70 Sheet 5 of 7 N/A OK NO ..u'�..,., „v �«. ..?°�.uz.uia�,:.,e t�m ra,;..wrocst�;;°4a�s�✓ �1?a.hK����,�,&�,"�.p�..x��,r,���� �-:r:..�° �''.,� �r��:.,-�ifist.���ac�ks €6 a�sio-, ���^<`: Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems >2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system -make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year (systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fill -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255.(2)(e)] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Alternatave�septic Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance y ,sf's"'s�.w�, ab' � F :��-r v'z� ,�° '� a��`s +�•.�",�-r, ��"K,� x ��.r E' ,�c�' °+ zk�+� Are the variances listed on the plan ? [310 CMR 15.220 (4)(q)] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.4141 Address Z?9��?O Sheet 6 of 7 N/A OK NO �. N,ti.,.itrogen 1jSe�isctzve Ayseas � � f� M5 y <xW x, ,., Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? _ / [310 CMR 15.214(2)] F/ Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] 11Tiscellaneousa„ Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] Address Z?9//70 Sheet 7 of 7 Town of Barnstable °FtME r Regulatory Services Thomas F. Geiler,Director * BARNSTABLE. + 9 MASS. i639. Public Health Division �� ArFDMA'tA Thomas McKean, Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# 2-'5efei ^ /i Assessor's Ma \Parcel /70 2 S' P _ e,. -Designer: P E Installer: Sear:- H. Address: �z,� izov ra e 'A Address: /i 3 be_D On S�� o g C'o�T y. =2,�.� was issued a permit to install a (date) (installer) septic system at 2717 based on a design drawn by (address) dated �� !B� / (designer) I certify that the septic system referenced above was installed u s bstantially according to the design,g , which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic, system referenced above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. �.lk �,;,��, o� STEPHEN G es o A. a^t .s ( sta ler s Signature) CIVIL No.35461 9EC►STT.a�® T (Designer's Signature S (Affix Desi ner s Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Revised.doc °Ft"E rQ►�, Town of Barnstable Regulatory Services Barnstable 9gA MASS.: g Thomas F. Geiler, Director 16,9 Public Health Division rFD MA't A Thomas McKean,Director Zoos 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 15, 2009 Ms. Tara Brown Bayview Real Estate 3220 Route 6A, P.O. Box 165 Barnstable, MA 02630 RE: Douglas L. Williams Dear Ms. Brown: The Town of Barnstable requires Title V septic inspections to be done by licensed DEP approved system inspectors who have registered with the Public Health Division of Barnstable. Upon checking with Rosemary Decie of New England Interstate Water Pollution Control, we have learned that Douglas William's licensed was revoked on July 20, 2007 for failure to renew. Mr. Douglas has also failed to fill out the proper registration form with the Town of Barnstable. We understand an inspection was done on the property of 279 Skunknet Road, Centerville by a licensed inspector. The property failed inspection on 11/12/04 and has not been repaired as of today. Douglas Williams performed an inspection on this same property and passed it. This inspection is invalid due to the fact that it had previously failed and also that it was done by Mr. Williams without the proper license. Finally, as of today we are in receipt of another inspection by a licensed inspector who failed it in 2004 and then again on April 10, 2009. Q:\SEPTIC\Doug WilliamsBayview Real Estate-279 Skunknet Road,doc.doc Centerville.doc If you have any further questions please call our office at 508-868-4644. Sincerely, Donna Z. Miorandi, R.S. Town of Barnstable Health Inspector Cc: Mr. Brian Dudley Mass DEP 973 Iyannough Road Hyannis, MA 02601 Q:\SEPTIC\Doug WilliamsBayview Real Estate-279 Skunknet Road,doc.doc Centerville.doc APR-13-2005 09:45A FROM: TO:950e7906304 P.1 Bayvxew heal Estate w�NabdYW0W4 eodcons "Ou a dwr doy you rms see jarrr�er„ �.. B,ers� SQ8 62-as43 ._._. 3220 Roide&4, P.a Bar 14 1 , bye, MA 02630 To: Donna Miorandi,Health Department Town of Barnstable Fax: (508)790-6304 From: Tara Schiffmann Brown April 13, 2009 Septic Inspector- 279 Skgnknet Tel: (508)362-8543 Fax: (508) 3624786 Cell: 774-810-6381 Dear Donna, In speaking with an attorney involved in the sale of 279 Skunknet Road in Centerville, he mentioned that if Doug Williams is indeed not licensed as an inspector in the Commonwealth it would be helpful if we could have a letter from the town to this effect. I understand from the listing broker that the town may have a record of Doug William's septic inspector's license on file already and that perhaps there is a mix— up. the h4s c011od Pagg to Olscuss the issue with him o#rpctlyj If you do have such a letter and could fax it to me at(508)362-4786 for my records it would be quite helpful. Thank you. Sincerely, Tara Schiffmann Brown "On a clear day you can see forever. " www.bayvi.ewcapecod.com �OFTHE Tp�, Town of Barnstable �.� Regulatory Services Barnstable �B"M SS. Thomas F. Geiler, Director nanmaricaC1W 039. Public Health Division ATED��p Thomas McKean, Director 11111.1 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 13, 2009 Mr. Douglas Williams PO Box 1069 Centerville, MA 02632 RE: Septic Inspections for Town of Barnstable Dear Mr. Williams: The Town of Barnstable requires septic inspections to be done by state septic inspectors who have registered with the Public Health Division of Barnstable. Upon checking with the MassDEP office, we have learned your state septic inspector's license was revoked for non-payment in July 2007. We understand an inspection was done on the property of 279 Skunknet Road, Centerville. The property failed inspection on 11/12/04 and has not been repaired as of today. Please address questions to our office at 508-868-4644. Thank you. Sincerely, Sharon Crocker Administrative Assistant Q:\SEPTIC\let inspector Doug Williams Apr2009.doc APR-10-2005 07:05A FROM: TO:915087906304 P.1 Bayvievn Real Estate me4ab°�'"e°peeodee" "O�c a clear do y you rax see fo�,e<w" _ Bra s00 62•dS4.� 2220 Route", P.O. Box 165. Barnstable, IVA 02630 Attention: Donna Miorandi,Town of Barnstable Health Department IMPORTANT Fax: (508) 790-1822 From: Tara Brown,Bayview Real Estate April 10,2009 Total Pages (1b) Tel: (509)362-8543 Fax: (508)3624786 Cell: 508-776-0868 Dear Donna, Please find attached the septic report for 279 Skunknet Road. Thank you for your assistance and follow through. J Sincerely, J Tara Brown "On a clear day you can see forever. " www.bayviewcapecod.com A ' Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Fcirm4rNot for Voluntary Assessments cl Property Address {2.u.i1— G .L.._ owner owner's Name information is required for C u c c.. [ "-... . . ..._.__. ✓L � �� .... .. � every page. City.'Town State Lip Code Date of Inspectio Inspection results must be submitted on this form. Inspection forms may not be altered in any way. - - - -- - - -------------------- ------- -------------------------------------------- Important: When filling out A. General Information forms on the computer.use 1. Inspector: only the tab key io move your cursor-do not ---r_L:._!�7_L�- -._�_. ' ry: use the return Name of Inspector ke uiC�p^c . ,c�(1�(t�M. ti l Company Oarne ----------------- --------.-...............- -------- --- --------...__... ---------------------------------------------- ------------------ Co patnyAddr'e City/Town State Zip Code .------------- 1'clephone 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 maintenancpQf on-sIte sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1,5,,340 of Title 5(310 CMR 15.000). The system: . ' Passes [] Conditionally Passes ❑ Fail's4, ti-o+ Needs Further Evaluation by the Local Approving Authority n 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP The original should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. ****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. .5•„sP o,,,. •'L/`J .i;ia:rXtice.. nslxcw;r.Nrm_.-:Ax;,Rare se,,iicw JL`:p:)s.,. ';srem Pa - ._ Commonwealth of Massachusetts Title 5 Official Inspection Farm Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :•_•.. Property Address .:._.....s�. .'. .-... ........................................--..........-..........-................—........------.-- - --- _.......---------------------------- — Owner Owners Namc information is ✓ChrJ t ��� — �� ��� 3 ��//� requiredfor . .. ...... . ..... _ .._.... ..._ .... _............. ..........-- --- . . .....-...-.. . every page. City/Town State Zip Code Date of Inspects ---------------------------------------------------------------------------------- B. Certification (cont.) Inspection Summary'. Check A,B,C,D or E/always complete all of Section D A) System Passes: I ha � '_t 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: - .._....._. r=M,-.-._.-.__....__.....-..............---- --- -- ------ ------------- ------------------------------------- --. B) System Conditionally Passes: ] One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N. ND) in the ❑ for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or on or an ure is imminent System will pass inspection if they existing tan ia- 'placed with a complying septic tank as approved by the Board of Health. / ` A metal septic tank will pass in! pection if it is structurally sound, not leaking and if a Certificate of Compliance indicating thai'the tank is less than 20 years old is available. ND Explain: .--...--..----...---.--- ----_-.--_--.....-.-..._-._...._..................---.-.---.-._...------------- --...--.--.--- ...---.....;'.--------------------...................................... Observ/ation of sewage backup or break out or high static water level in the distribution box due to bt6ken o obstructed pipe(s) or due to a broken; settled or uneven distribution box. System wiL pass`s r inspection if(with approval of Board of Health): i ] broken pipe(s) are replaced obstruction is removed .;�;�,_>.cc• T-� .:-� � Fwrn�SeUsurtuce Sav�ape:s xa!ss•>�,.. .., Y Commonwealth of Massachusetts -� Title 5 Official Inspection Form -' Subsurface Sewage Disposal System Fo Not for Voluntary Assessments 9 p Y Y r. C �6L L I/ - - .._.._._... ,.> �>�.v 1 .✓Lt C . Pro perly Address Ownct owner's Natne ,nformation is AA rZ(1,7`Z— required for C,"71 t ,t9G.._.'E- /1l i7� C .. l / every page. Cityilown State Zip Code Date of Inspection - —------- -.---------- —--- —--- ----- ----T----------------- ----- B. Certification (cont.) B) System Conditionally Passes (cont.): distribution box is leveled or replaced �f ND Explain: ` ❑ The system required,piimping more than 4 times a year due to broken or obstructed pipe(s). The system will pass I)-tspection if(with approval of the Board of Healthy ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Ex ain: 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: ❑ "i Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environm9nt: [] The systerT has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet/if a surface water supply or tributary to a surface water supply. ❑ The Otem has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ T e system has a septic tank and SAS and the SAS is within 50 feet of a private water upply well. tirsp co, .aie CYiiCa:!nspenon corm:Fiutr•udare:Sewage Duwsa!System•Page d 1 y Commonwealth of Massachusetts Title 5 Official Inspection Form x - Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Uv✓ner owners Name information is (� / required for t. .. every page. City./Town State 'Lip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well" Method used to determine distance: " This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presene e of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no oth0'r failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ....._......—--- -----__---------._.-.-..!...............----------------------......................-._....-------......_._.................._.__.... -- - -- -------------- ............................-........... ................--........_......._..._......... ....._......................................................................._.......................................... _........_.....__...--r..--..---....-.......................-......-- .--......................._.-..........._........._._._._...- - -- ---- -- --- -- ----------- i 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 1L�--- 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 �—� 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 vrater elevation ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply of � Ibutary to a surface water supply. ..,.r.p ,`• v% '.'i;ie 5 Chiral inspeccen'Form'SuUsudare sevis Pe 01sws3!30!eT•Page 1 ------ — Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments PropeA Address t . owner's Narne L7 information is __._ .�.1..,.....- .._/ C� 1 t2Guirod Io: ` _.....-.. . . . -.. Date of Ins ection - every page. Ci own sate Lip Code B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No �] Any portion of a cesspool or privy is within a Lone 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.] . r] 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 __c...riteria 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 systern is In 400 feet of a surface drinking water supply [� [] the s em is within 200 feet of a tributary to a surface drinking water supply ❑ e system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped lone 11 of a public water supply well If you have an,veered"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. .;tie`.Onf1c;a,Inspecc n:Prim Guln:;:rture j�evrge D'scfna!3+ste-n-Page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PropertyA tlress ___— _.._ .--._... ------L.................... ----------- --.................... - ----- -...---- ---- - ---- OwnerQwiner _............._._..._....._._.....__....._._.._....r._..... _..._.. -------------_..-......._.infar,-nauon,s 's Na e --tequired for for ( L7 c every page. City,'Town --------•------- ate 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 1' � [] 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 —7 )k- 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? WCT the site inspected for signs of break out? ere 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 U information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has beer)determined based on (J 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 n approximation of distance is unacceptable) [310 CMR 15.302(5)] r pie.`:�WiCin:inspe<Urr.rorri S.b.,urtar:e Srir:;gn 015r n f Page?V ' Common.wealth of Massachusetts !V __ Title 5 Official Inspection Form r - {�i Subsurface Sewage Disposal System Form Not for Voluntary Assessments - -- P(operly.Address ., J Owner Ownor's Narne information i5 equired for �GG l._.. ......_C...................._ .......-._. ' every page. Ctty'Town Stale Zip Code D,to of Inspection ---------------------------------------------------------------------------- D. System Information Residential Flow Conditions: Number of bedrooms (design): ' Number of bedrooms actual) DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms): Number of current residents: - -"-- --....._.- Does residence have a garbage grinder? ❑ Yes ?lam. ^;o Is laundry on a separate sewage system?(if yes separate inspection required) ❑ Yes No Laundry system inspected? Yes [I No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)). .L ...A.7_.. Sump pump? ❑ Yes Last date of occupancy: ) Commercial/Industrial Flow Conditions: Typeof Establishment: ---•---- --------...............__...-;..----------.__.___..................- Design flow(based on 310 CMR 15.203) ------- s p day(9pd) Basis of design flow(seats/persons/sq.ft., etc.): -------..... ............------------ Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Q Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes i f•;o Water meter readings, if available ---------._ - --- ----- - - Last date of occupancy/use: oaie----------... Other (describe):. .....------------------------------------------- ------- --- ._.._._..... r - Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addross j fL Owner Ovener's NarId mformanon!s (/�� J(�! U. every 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.): _... ..._.._. .._.._.._......_..lM(L ` _vk_..__._ ?-._cc�. ..................am --- _........- _._.__.___.._........._._..._.....------._............. Grease Trap(locate on site plan. Depth below grade � ro t --............-......-..................... ------------- Material of construction. [_] concrete ❑ metal [j fiberglass ❑ polyethylene ❑ other(expia n Dimensions: .......................- ------ ------------------------ Scum thickness _..... _.... :.. .. .. .._ Distance from top of scum to top of outlet tee or baftlF:..... Distance from bottom of scurn to bottom,€-nutlet tee or baffle - --------- --- .......... -------- Date of last pumping. ; �aie---------._.....— --------------- Comments(or) pumping recoJ�mendations, inlet and outlet tee or baffle condition, Structural integnt;. liquid levels as related to outlet inverrt, 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. L� concrete [_ etas (_] fiberglass [] polyethylene ❑ other(ex.pia n. „�-•. •_�...` !.',if.E<:lillFil!n5(WCCC!`.FJfm.$L'U91;(:OCe$EYlil(fr•0!51;0X3!3761em I Page 11,01 :; r - Commonwealth of Massachusetts - ; Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1 e T� �.,.v Property Address -,a' .. �_ _-- _` L.---.... .... ...........-._..._._._....._ _ ............... --- - _ - -.--._.-.-..__..._.. ._._....-.- - ---- ----.- ---------------- -_._.-..- Owner owners Narr mtormation is _n I �1 q/,• /•��� regwred for Cz 2W4 � C........._ �! . . G' ._ ._ ! _..._.. ..,. every page City/Town State Zip Code Date of Inspection -----------------------------------------------------------—----- ----------------- �— D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet ___..._.-.-...__..............._---------- Material of construction. EJ cast iron ❑ 40 PVC y.- �_� other(explain): ......................------------------------._.....----------- -------------- Distance from private wat.Q�supply well or suction line feet Comments(or) condition of joints, venting: evidence of leakage, etc.). Septic Tank (locate on site plan): Depth below grade: f t r -s -. .. --._...-.--.-.-.- -__... ee 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: -- - - --� -------------- Sludge depth: --------- -------- • --- Distance from top of sludge to bottom of outlet tee or baffle --.........._... '—--------------------- --- .:. -._...._...._ Scum thickness `. _.._...-.--_.-____-- -- Distance from top of scum to top of outlet tee or baffle -------- - ....L---------�-- -------- Distance from bottom of scum to bottom of outlet tee or baffle ---------- - -------------- - How were dimensions determined? !::ie`iYii;ig!!n• ,eCdr n i 0Qfm -S!:!YY1r';Jrl:Si^iPi'e:AS'75a!J s em•Page�G _+ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PrcPeer__ty Addross ` l_Uw. ...... Grv..I� . Owner owner's Narne; )+ 1 information is /; ��� l ;equhed for � � '. .. ��:._.-. _.-.........._............. ...__......__... every page City;Tovm state Zip Code Date of Inspection ------- ------------------------- ----—----—----—----------------------------- ------—------------ D. System Information (cont.) General Information Pumping Records: .C:_ ...-._... .! `_r��� _._..._.......�yv�--- ---------------- Source of information -- c,� Was system pumped as part of the inspection? [_} Yes T No Ifyes: volume pumped: ....................................-.........................................-......... ,—�--- - - gallons How was quantity pumped determined? ............................................................-.......................-.............--------- -- Reason for pumping. _._.. Uf._ .. ..._....._..__._.-.... --- .....-------...._._._.... Type of System: Septic;tank, distribution box, soil absorption system [] Single cesspool Overflow cesspool [_] Privy [J 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) L] Tight tank. Attach a copy of the DEP approval. [] Other(describe) Approximate age of all components. date Installed (if known) and sou t 00information. ---- --_...................- - --- -........._.._..._.._._ __._ ._ _ - �.q F ------------------------.._..._........... Were sewage odors detected when arriving at the site? ❑ Yes No !':tie f.Offida!inspemn Fe n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r L 52'r.-penyLddross ..................._......-..........__._................__.__...................... ............. Owner Owners Naine regi.iired fol t every page. City.Town state Zip Code Date of Inspection ------------—------------------------------------------------------------------ D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: _.._...............................--.............-.._.......--'-------------- Capacity: ..ga ll..-'-_on3-�'__.._....._,_........ -...-'-------------'-'-----------'---- lam, n Desig Flow: ;^ .-'-gallo---'-ns-..per ...ay_-....._...._.I._.-_......--'--'-- ' d Alarm present: ��'^ C7 Yes [j No Alarm level: ------------/-------------'- Alarm in working order' [] Yes LI tic j% Dateof last pumping: 1/ -'Ua t--- ....---'-'---------'-----'---_._._...__.........._----------.....__............._. e Comments(condition of• larm and float switches; etc.): -------------------................ .........................------------- - ------------''' ''- -'''''-''''-... ._...._...__._...-'''-'-'-''-'-'-'-'---'--------'--- - ` Attach copy of current pumping contract (required). Is ropy attached? ❑ Yes ❑ t•Jo Distribution Box (if present must be opened) (locate on site plan). Depth of liquid level above outlet invert ..................................................................... Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage Into or out of box, etc.). Pump Chamber(locate on site plan): Pumps in working order ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i;r>:;o;:c• '!me f.oificial insrx�ction Form 98xr.;riare���rr,;ye O�sWsa!5•;;te^�•%agr . Commonwealth of Massachusetts y :M ;I, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :... :J ()lo N Property Address Owner Owners Na mfontteliJn t5 �. required for 7-.7...... C _.. every page City.Town State Zip code Date of Inspection ----'--------------- ---------------------------------------- ---------------- — D. System Infor— mation (cont.> _ Comments(note condition of pump chamber, conoi.tio-Kof pumps and appurtenances., etc.): yc:......_..._..............._...._.-------------------------_.....__............—..............._'—'----'--.—.._.----.. _...._...._.._._....---._.._................. ___...----...__.___....._.j./....._......._......................_..._.._.____._._.__-._...._...._._..._..__._.._.___...—'—'--'--'--'---'--'--'------'-'---- Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ...............................-............_._ c!:_ _��.`._..._-.-'%._...................................._.__.._.__.......-•---'-.. _-----'--'---'--'----—------ Type: leaching pits number ---/-------- ❑ leaching chambers number: --------------- �] leaching galleries number: - ...- -....- ❑ leaching trenches number, length ❑ leaching fields number, dimensions: ------- --------- ❑ overflow cesspool number: -- ------------- , ❑ innovative/alternative system Type/name of technology: --'-'--''-'-...''-'-- - --''----'------ ----- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _.......................... '-.............. ---'-......''.......... -- ------- i,r•su..c:•'.:7.,? T;, '',Cwc�;al!ns7zcur,�t FCirn-`i�:n,;r:;iru Sewa�oe DesF>sa!-iyi:6': ?agr _ Y, CommQnweaith of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address J Owner - ---'--------------__----._. _._.."_.....__..._. ................. ............. _...........................................---'-----'-----'-.........-'-'--—-------- ------------- owner's Na e information is �} ,A/�/�, requ ired for � .._t.C... ....._.. .. .......... ,.__. 0��--- every page. City/Town state Zip Code Date of Inspects -------------------------------------------------------------------- D. System Information (cont.) 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 scurn layer ,• l -'--'---'--.....-------------- --- Dimensions of cesspool �f — ------- ---- Materials of constrruu on --.-----._.---- ---- Indication of grr ndvdater inflow ❑ Yes ❑ No C Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.j Privy (locate on site plan). Materials of cortstructi = o Dimensions ------_._................................................-..........------------'---------- Depth of solids --- Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.): •;i,n5')cx•::... !'pie`)<Wicird insxcCrr.�roim:Sutwurtar,r.�e�roge liisu�sa!3ys:am,•rage ;;. . .- F <9t. Commonwealth of Massachusetts r -Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.. ... v ,, Property Address lL Owner Owner's Name / Informations T /ZL,ZC� ��f*V 07�3� req;!ired for �`� { ........ .. ........ every page. City/Town State 'Lip Code Date of Inspection ----------------------�—_—� _ -------------------------—---—---------------------- D. System Information (cont.) Sketch Of Sewage Disposal System. Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks of benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. L� —j I P it C 3e r r •-D C z i • C -103 v r,,;:<:;::;;:• !;:' . !;tie .y;.... � 5::!r.;:;dace Sr•�r;ce U!svx:a!:;•;stew..?,gr .- .,�e`„��.�!insxccor.F�rn� .. .. F r Commonwealth of Massachusetts - 3==; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �:. Property Address—`-----•--------� ----------.............._-------- - .._.._---------------.....------.....----- ----------------------.... r Owner Owners Name information is requiredfor �.....,.. .... _...._.... ._.. ........ .... -•-- - C-'- -...._.... _..._.... every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ;CIeSlope Surface water Ch cellar Shallow vrells Estimated depth to high ground water: --- t --� --------------- ---..--- . foo t Please indi ate all methods used to determine the high ground water elevation: Obtained from system design plans on record 2 Z ........... If checked, date of design plan reviewed: pain ...............:-. . ---- - ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain'. 5� ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database- explain. You must describe how you established the high ground water elevation: ------ --------------- -- 1- .._... _....__ t3 .�- -------- ------------- _ -------------- N_.. Sn 1t iN%z _--- .U� ,r�._�y-.-cr... --..-.�:-.....__ .n..�C. ._._._.✓- �../�'�_._..__.-. -..__._._...w.J ...........r iv........... .::/.....................`r> l 5.._._.._.. '__...._-S ....%....................-....... ._._........ .............`............%n-........_.......--........................--------------------------------....-.------------ .._..._._._--__...........:... ;.imsu.00:• ".:J7 T Ve 5(.)!fida:!nS-.Rnot:Fern:5u n;;riare se-m-ge 0!sr Jsa! l n 1 f f— 4 � Co c� e TH C O � X DPI" O � � ®'� �'��®ITT BE IT KNOWN THAT m co Dough L. William Has satisfied the Departrnent,s qualifications as required and is hereby, W authorized t® tise the title- CL,RTNIED TIT LE 5 SySTFM INSPECTOR as provided 310- CNIR 15.340 and Seetio-0, 13 of Chapter 21 A of the General Laws. issued by The DeparUnent of Environmental Protection. :lay'i, x+^` �r n o 1"i4YeCFE:F f1El fJi�!}tl:v'�Stdi11 Ur Watee 0 • fV M 3 -p N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not Jor Vo'unt2ry Assessments Property Address Owner Ow r's Name every Pace. Citv/-rown State Zip code 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. When fi0ing out A. General Information forms on the computer,use 1. Irnspe or: only the tab key Lo move your cursor-do not Name of Inspector use the return Co p2ny Na Company 1dress City/T0%vQ State Zip Code B. Certification I certify'that I have personally inspected the sewage disposal system at this address anC 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 ol,I o n sit!e sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of 1-0 F� Passes Conditionally Passes I Fails 2: <a-�Js` El Needs Further Evaluation by the Local Approving Authority la" jInspect r's S-ignature Date The system inspector shall submit a copy of this inspection report to the A-por P. i of Health or OEP)vvhhin 30 days of completing this inspection. If the system is a ehere(� oyate-: or | haoadesignflovvof1U.00Ogpdorgneater. thainnpeoorandtheaystemop/nershsi/ outmift.-o naportto the appropriate negiona| office of the DEP. The original should be sent The oyster- ov`"er and copies sent to the buyer, if applicable, and the approving authority. ~~~This report only describes conditions at the time ofinspection and under the conditions Of use at that time. This inspection does not address how the system will perform in the future under L` the same or different conditions ofuse. , t5ins-oaloB T"flesoffic;a/ r,,r" oL,�`=�" | . ^ ` � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsufface SewagelDisposal System Form Not for Voluntary Assessmerts ProPertv Address Owner Own Name required for every page. City/Town State Zip Code Datecf in .�- Cn B. Certification (cont.) Inspection Summary: Check A,B,C,D or EE always complete all of Section D A) System Passes: F�, I have not found any information which indicates that any of the failure criteria descrited indicated below. B) System Conditionally Passes: 101 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 app,o%led by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If;�Ict determined," please explain. The septic tank is metal and over 2U years old*or the septic tank (whether metal ornot) is s|nuc'unaUy unoound, exhibits substantial infiltration orex�|t�tion or tank fai|ure is ir�mine:t. System wiUpass inspection |f the existing tank io replaced vvitha complying septic tanhasapprovedby�he Board of Health. � °Ameta| noptictankwiUpansinspeotionifitinnhncturaUyaound. not |enkingandifaCet,!iostec� � Compliance indicating that the tank in less than 2O years old isavailable. | El Y 0 N F� ND (Explain belovv : | mflaso��/ms!)e-m��.ouias�'-s �ec�="��=� ���''` r Commonwealth of Massachusetts Title 5 Official Inspection Form ,; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -.. i _. PropkrtyAddre Owner Ow is N m inform2tion is required fore^Tom'''f/i /' _ /v .------ ever,,,page. City!i own State Zip Code C2 I e of;r �o �.;on B. Certification (cont.) B) System Conditionally Passes (cone.): ❑ 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 brcken, settled or uneven distribution box. System 1.v! pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NC (Exp'Gi be'o ): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain be e,a1): ❑ distribution box is leveled or replaced ❑ Y ❑ N L II ND (Explain 11,e:.o,,v): ❑ 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 cete 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 CIMR 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 weuand or a Su;` `na'S'_ tSa=-.nc!08 Tile 5 Ccrizi Insc_dic.=o-^:S;,.__-a_e Se ;__;_ �:_:.-•____„:. - | � ^ ` Conmm()nVVg8|Lh of Massachusetts ~�.~4���� �� ��.���"��"��� N����������4�~���� ����U���� Title �� ���00U��U��U Inspection �—��noxx � Suhnurfaca Sewage Disposal System Form - Not for Voluntary Assessment's Prop Ad.dress Owner « /7. mm,msoon/, required�orIle— every pago C/tyiTown S�ate zip Code oyts ov|nsreu000 B. C«aotx//caat|o/r (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: Fj The system has e septic tank and ooil absorption system (SAS) and 'the SAS is v/i�t|n | iUO feet ofa surface water supply or tributary toa surface water supply. � F-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of pubic�vs�a/ supply. �1 The system has a septic'lank and SAS and the SAS is within 50 feet, of private supply well. ^ The system has a septic tank and SAS and the SAS is less than 1ODfeetbu� 5Ofeetor more from a private watersupply weU°^ Method used to determine distance: This system passes if the well water analysis, performedotaOEP certified |abonatory. for oo�onn bacteria indicates absent and the presence of ammonia nitrogen and nit.rate nitrogen is eada! to or less -than 5 ppm, provded that no other failure criteria are triggered, A copy ofthe 2re1ryn/a must ba attached to this form. 3. Other CA System Failure Criteria Applicable to All Systems: | You must indicate "Yes," or"No" to-each of the following for all inspections: Y 71 Backup of sewage into facility or system ue to overicalfed clogged SAS or cesspool due to an overloaded or clogged SAS or cesspool Stati liquid leve! in the distribution box above outlet :!nvert, dlul=- to 2n r clogged SAS or cesspool Liquid depth in cessQool is less than 6"below invertor avallabln ,`c' Commonwealth of Massachusetts =_ Title 5 Official Inspection Form Y 5) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ----- - ---- ------ Property dress J r l Ao w L✓� c�G.r► �(/ Owner Ownn' Nanne — --- ---------------- required for every page. City/Town State Zip Code Dace of!. so 4, 4 B. Certification (cont.) Yes No ❑ equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ny 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\yell. ❑ [ y portion of a cesspool or privy is within 50 feet of a private `,'Dater suopiy,Neil. ❑ Any portion of a cesspool or privy is less than 100 feet but create,-than 50 feet from a private water supply well with no acceptable water quality ana'vsis. [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 chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000epd 10,000gpd. ❑ The system faits. 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 1Viil 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 addi=ion to t^e questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface di-Inking '.valet suop!•,.r ❑ ❑ the system is within 200 feet of a tributary to a surface drinkini ::'a yr s po' ❑ ❑ the system is located in a nitrogen sensitive area (Inter m `'ilei.',eat :D. -;c.n Area — IWPA) or a mapped Zone II of a public waters piv el' If you have answered "yes"to any question in Section E the system is considered e sioni ica-; or answered "yes" in Section D above the large system has failed. The --er or system considered a significant threat under Section E or failed under Section D stall uc a e e system in accordance with 310 CMR 15.304. The system owner should contact the regional office of the Department. t5;^s•oeioA Title 5 Offi-i?I in,s.7Gc.;cn Commonwealth of Massachusetts = � Title 5 official Inspection Form ME ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessmehts z ,_� (�, Q Propert Address ON N Owner Ow Na, . _ — -------- --- information is required for o y -/ M ou-�,j;� A, every page. City/Town State Zip Code Date c"lnsr tior C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the fo"c,,-!inc: Yes No ❑ Pumping information was provided by the owner; occupant: or Boa.d of i eai i± ❑ [� Were any of the system components pumped out in the previous :!o ;reefs? ❑ las the system received normal flows in the previous two week perioc ❑ Have large volumes of water been introduced to the system recently er as aei. of this inspection? ❑ Were as built plans of the system obtained and examined? (If they ,^:ere nct available note as N/A) �❑ Was the facility or dwelling inspected for signs of sewage back lip? �❑ Was the site inspected for signs of break out? ^�_ ❑ Were all system components,,Fe'trdi>?c-he SAS; located on site? L� i❑ Were the septic tank manholes uncovered, opened; and the interlor of the tar:' 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 information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) or:. the site has been determined based on: L� Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure crier is related to Part C is at issue approximation of distance is unacceptable) [310 CM—r,\ 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): �- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x of bedrooms): tying.per08 Title 5 ofida!Inc+ectio^F,;-n: Se::•=ce Commonwealth of Massachusetts — Title 5 Official Inspection Form _= r, Subsurface Sewage [Disposal System Form - Not for Voluntary Assessments h'-G� y✓ Prope P.ddress L, _ 1 C Owner Owne ' Nam ----- -- information is � vi Ile , �/JAevery for _ _ /tale y o every page. City/Town u State Zip Code Oates.i.;r ns?e��;..n D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ✓No Is laundry on a separate sewage system? [if yes separate inspection required] t_j Yes o Laundry system inspected? J Yes I Seasonal use? 71 Yes Water meter readings, if available(last 2 years usage (gpd)): ---- ------ Detail: t� 0 710//0 [.,/--- -- Sump pump? ---- [ ,Yes _ Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: ---- Design flow(based on 310 CMR 15.203): Gallo-is per da _) Basis of design flow (seats/persons/sc.ft., etc.): — -- - Grease trap present? Yes No Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? `os Nio Water meter readings, if available: thins-og/o8 - Title 5 official inspec5on=oc sues,_-=c=,= c -- - - Commonwealth of Massachusetts _) ,6 Title 5 Official Inspection Form -,, !=i Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments Prope y Addres Owner Owner's Name 67— --- — - information is required for l-d�N_ ✓(/! --- A every page. City/Town State Zip Code Dat= inspection. D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: t Source of information: H-� /ZSC-g-a � °�%�' Was system pumped as part of the inspection? ❑ Yes if yes, volume pumped: gallons How was quantity pumped determined? -----= Reason for pumping: -------- Type of Sy Septic tank, distribution box, soil absorption system ❑ Single cesspooi ❑ 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, a�C maintenance contract (to be obtained from system owner) and a ceov o`la`est inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe t5ins•09/08 Title 5 0 57ai 6ns0ec'i0n Form:Su:_. , =_. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Pr lsddrZes Owner 0 er's N me� information is Lo required for Vol, every page. City/Town State Zip Code Date of spe"ct;cn D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes Ne Building Sewer(locate on site plan): Depth below grade.- leet Material of construction: ❑ cast iron ;'4_0_P�vc 7 other(explain): --- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Materialfeet nstruction: ccncrete El metal El fiberglass El polyethylene ❑ o"-fer ex iainl H tank is metal, list age: yeZrs Is age confirmed by a Certificate of Compliance? (attach a copy of certi! "::1=" ❑ Yes No Dimensions: Sludge depth: t5ins•09/08 Titie 5 cffi-iai irsoect;o,Fore:s Commonwealth of Massachusetts - Title 5. Official Inspection Form f' Subsurface Sewage Disposal //System Form -Not for Voluntary Assessments Prope ddress Owner O is Na, e 7 r information is rem required for ----- every Page. City/Town State Zip Code Date o In pection CD. System Information (cont) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle - --------- Scum thickness -- Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, licluid levels as related to outlet invert, evidence of leakage, etc.): c .7 c-1.1-, en s Grease Trap (locate on site plan).- Depth below grade: feet — Material of construction: ❑ concrete. ❑ metal ❑ fiberglass ❑ polyethylene ❑ ohe. (ex.:D'ai,n): 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: Data Title 5 o-,_,al!n cection=or,:Subsu;- S=V== Commonwealth of Massachusetts Title 5 Official Inspection Form .II Subsurface a Disposal stern Form -Not for Voluntary Assessments surace Sewage P osal System Proper}��1Qddress ---- Owner Ow e%s Na e -------_- information is �l required for `te e✓y� r `/�E_ //" �7�` /V _P/ every page. City,'Town State Zip Code Date cf In e- ®. System Information (cont.) Comments (on. pumping recommendations, inlet and outlet tee or baffle coed tion. structure! 'ntegrity, 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 (exp':eir): Dimensions: Capacity: ----- gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ! -I Yes i i 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 iJo sns•o�os Title 5 Official Irspect;cn For: Commonwealth of Massachusetts F.A�� ;K Title 5 Official Inspection Form 1,1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `-J ?—Ir Y Addres — / -- Vt N G�.t. — v. !✓ Owner Owner's Name information is rewired for _-- _ — --------------. every 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 -- 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.): 6,0 V- 4-�117 - - Pump Chamber (locate on site plan): Pumps in working order: I I Yes No I Alarms in working order-I order- L Yes ❑ No Comments (note condition of pump chamber, condition_of pumps and appurtenances: etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: (sins•09!08 - - Title 5 ocidal commonwealth of Massachusetts Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Pro Y y Address O Ov.'ner owe s Name I�] ----- — ren_uired for '�N' ✓� even,page. City/Town State Zip Code Date of Ins-.:tion D. System Information (cost.) Type: / e- e'Ar leaching pits number: ❑ leaching chambers number: -- - leaching galleries number: ------ — ❑ leaching trenches number, length: ------- ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ----- ❑ innovative/alternative system Type/name of technology: - ------ Comments (note condition of soil signs f hvdraulic failure, level of ponding, damp soil, condition) of vegetation, etc.): oh �N s toe C✓ INve��- C-L C_- 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 ❑ Y`s No i5ir•s.09,,oa Tile 5 0 5dal Inspecilon Fom:Su^sc =c=S= __= Commonwealth of Massachusetts mw `title Official Inspection Form Ur ✓ Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments Fr"hr r� � (ram = 2 — �citi Owner O �'NName V4 (/ O m 67— information is (/ required for every pace. City/Town State Zip Code Date of Vsoec cn D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure; level of pondin.g, condition of vecetaticn, etc.): Privy (locate on site pian): Materials of construction: — Dimensions -- — --- Depth of solids — - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition�� of vegetation. etc.): 15i s•09.'O8 Title 5 0-icial Insoecti-on=_ s,„s❑ -=c -- Commonwealth of Massachusetts Title 5 Official Inspection Form \L` MCI; Subsurface Sewage Disposal System Form -Not for oluntary Assessments �Pro rtv Addre L4 N —Owner el's Nane - - ---Owner Information is required for �'� ---- - 6 _ every page. Ci y/Town - -- State Zip Code Date of!nsp on n� D. System Information (cent.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system; inci.uding ties to at least two rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately IF ,14 10 i v . I a j I �3 -36 i ;Sns•09/08 T,'Je 5 Offinal lnsneo8on 9o: c,.-- Commonwealth of Massachusetts = t "Title 5 Official Inspection Form q�-� ,' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments h fQ /, �.� 'g% Pro 'erty Addr DVl Owner Owner's Na required for information is Co 4-A � � 0 0 _ _ every page. City/Town State Zip Code Oae of( spe tier, De System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / 20 Estimated depth to high ground water: ----- ------ -- feet Please i cate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: pate erved site (abutting property/observation hole within 150 feet of SAS) Checked with locaI Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: pla P7 Before filing this Inspection Report, please see Report Completeness Checklist on next page. :sine•09i08 Title 5 oKciai!nso=cion.Fern:SeCsu�=•-= --.,- _;__a __—•-- - Commonwealth of Massachusetts Title 5 Official Inspection Form _ = Subsurface Sewage Disposal System Form - Not for Voluntary Assess er:s — --- Ovdler O Y 5 Na ^cw ' Jiy(i own - State Llp Code D8i- c. ;-7 = E. Repo ompleteness Checklist --- - --- -- — lJ lnl;, �cton Su!�Omary: A, B, C. D. or E c iecked 1 Ins ion Summary D S stem Failure Criteria A licabie to All Systems) com,o:e ec' -J Y � Y PP � Sys' m Information — Estimated dept to high groundwater I Sketch of SeW2ge Dispose System either drawn or: pace 15 or attached i7: J" r --elV1-1)19edlo I,) o � 1�evil , le,:,G G, d 0(2 use hG o F/0 o '� L G IV? l4-6 Gt h -)C, 61v 2 c i Marc Pols:Ili office t508i ??,5-?' . _ cell (508) 280-7750 ENVIO-TECH D.E.P. CERTIFIED • MASS-LICENSED - SEPTIC INSPECTIONS PERC TEST SOIL EVALUATIONS CLASS 4 W.-kSTENVATER. OPERATOR r z6 ,z COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION K"El TITLE 5 ,aY OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A Q C CERTIFICATION Property Address: / ✓ ��n�p A Ad Owner's Name: ►^/ �, Owner's Address: Date of Inspection: CD Name of Inspector, lease R ( pint) Company Name: NV�0�- ` r.{ Mailing Addxesa x ` Telephone Numbe _ c.f y „M CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informa below is true,accurate and complete as of the time of the inspection The inspectio tion reported n 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 s Further Evaluation by the Local Approving Authority Fails Inspector's Signature:NQZ-,/-4a Date: /oZ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 3o days of completing this inspection.If the system is a shared system or has a design flow of lo,000 gpd or greater;the inspector and the system owner shall submit the report to the appropriate DEP.The original should be sent to the system owner and copies sent to the bu applicable,regional and the approvi ng authority. yer, Notes and Comments ��'�� /t t: Fci) ..1(4 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.ThiI inspection dgeq not address how the system will perform in the future under the-same or different conditions of use. V " Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C�/E,RTIFICATION (continued) Property Address: ✓S I'1'N h ArnC,� eo OwHer: /1 ff V, / Date of Inspection: // Inspection Summary: Check A,B,C,D or E/AA,Y complete all of Section D A. S stem Passes: 1 have not found any rmapo which info n indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CM1t 15.304 exist Any failure criteria not evaluated are indicated below. Comments: a Sy m Conditionally Passes: Qne or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined'please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection.if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: �7 0 r i ppge 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 99 n k"f' �_ Rc ✓i Od 63d. p°�vner. Bate of Inspection: // Id- C. Fu 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 failinpto protect pUb -health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR M303(l)(b)that the system is not functioning in a-manner which will pretest public health,lafety.and the.envirenment• _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unlem 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 tankand soil absorption system(SAS)and the SAS is within loo 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 t of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compwrnds_indicAes that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3, Other: t� r ! v� Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) rimperty Address: 02 �9 —541(1 h owner: GS Date of Inspection: / d OY D. System Failure Criteria applicable to all tystemy; You must indicate"yes"or"no"to each of the following for all inspections: Ye�No ✓✓' kup 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 ✓ S c liquid level in the distribution box above osspoolutlet invert due to an overloaded or clogged SAS or quid depth in cesspool is less than 6"below invert or available volume is less than /:Required pumping more than 4 times in the last year NOT due to clogged or obstructed flow times pumped pipe(s).Number nary portion of the SAS,cesspool or privy is below high ground water elevation 'W portion of cesspool or privy is within 100 feet of a surface water su w ter y, l >x or tributary to a surface portion of a cesspool or privy is within a,Zone I of a public well. Y porirori of a cesspool.or privy is within 50 feet of a private water supply well. _ Amy 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 duality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or legs than S ppm,provided that ng other fail are triggered.A copy of the analysis must be attached to this form,} ure criteria (YeslNo)The system U-4.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 des$n liow of 10,0t10 gpd to iS,000 gpd• You must indicate either`yes"or"no"to each of the following; (The following criteria apply to large systems in addition to the criteria above) Xtlhe system is within 400 feet of a surface drinking water supply system,is within 200 feet of a tributary to a surface drinking water supply stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone__ f a public water supply welt If you have answered"yes" to any question in Section E the system is considered a significant"ycs" in Section D above the large system has failed.The owner or operator of any lag �sib a tiered significant threat under Section E or failed under Section II shall upgrade the system in accordance with 310 CMR I5.304..The system owner should contact the appropriate rrgional office of the Dcpartment, i page 5 of 11 OFFICIAL'NSPECTION FORM—NOT FOR VOLUNTARY .. ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 1 /� I CHECKLIST Property Address: C � % ku h"e Owner. 6301, Date of Inspection: I /d Q Check if the following have been done.You most indicate` es"or"no"as to each of the followingr. Yes No ✓ g information was provided by the owner,occupant,or Board of Health were any of the system components pumped out in the previous two weeks system received normal flows in the previous two week period Have largevolumes of-water-been introduced to the system recently or as part ofshb inspection ere as built plans of the system obtained and examined?(If they were not available note as N/A) as the facility or dwelling inspected for signs of sewage back up as 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 7theor 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 — / sting 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 ap ximation of distance is unacceptable)P 10 CMR 15.302(3)(b)] pro page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION property Address: a 9 S� b'� �� ry►' OdL 3� pvvner. Date of inspection: / d RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33�p Number of current residents: L___ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es or no):TV [if yes Laundry system inspected(yes or no): /0 separate inspection required] Seasonal use:(yes or no):-1 Water meter readings,if available(last 2 years usage(gpMy Suunp pump(yes or no):M Last date of occupancy: rn//en COAMMCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1 S.203): 99)d Basis of design flow(seats/persons/sgft,ete.): Grease trap present.(yes or no):_ Indbstrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes of no):_ Water meter headings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFO ION Pumping Records. Source of information: �v Was system pumped as part of the inspection(yes or no):If yes,volume pumped:_____gallons—How was quantity pumped determined? Reason for 9: TYp SYSTEM ptic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool .—.Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _.Tight tank ._Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date i stgcd(if lmown�and source of information: OCT lj¢ Were sewage odors detected when arriving at the site(yes or no): Y119 f , page 7 of I I OFFICIAL INSPECTION FORAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1n SYSTEM INFORMATION(continued) �Address: / 9 ,SA(k n�-„,4- flG eo r�i Inspecti P Owner. Date of on: BUJOLDING SEWER(locate on site plan) 91 Depth below grade: �l Materials of cons 'on:_ st iron —�0 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of 1 eakage;etc.): SEPTIC TANI{s_(locat.7 site plan) Depth below grade: Material.of construction. �Concrete_metal—fiberglass_polyethylene --other(explain) If tank is meW certificate list age:_ s age confirmed b,a Certificate of Compliance(yes or no):—(attach a copy of Dimensions: X g Sludge depth: /197 r— Distance from top of sludge to bottom of outlet tee or battle: Scum thickness: /O'!f- .Distance from top of scum to top of outlet tee or bale: ,A Distance from bottom of scum to bottoi outlet tee or bade: of How were dimensions determined: lQa Si c Comments(on pumping recommendations,inlet and outlet tee or ba81e conditio as lated to outlet invert,evi o leakage,etc.): stnict'M integrity,liquid levels T`aNl✓ .IT �rN Qn Yl' ��acL ,S�i,i�tG TAN GREASE TRAM: (locate on site plan) Depth below grade:_ ( )Material of construction:_concrete_metal_fiberglass---Polyethylene_other Dimensions: Scum thickness: Distance tram top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet toe or baffle: Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or baffle conditio as related to outlet invert,evidence of leakage,etc.): structural integrity, liquid levels i page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) t Addreaa: a 79 u�►� - R� Oyvner. 141,4 Date of Inspection: ,t 0 } 9 ` TIGHT or HOLDING TANK: /y (tank must be pumped at time of mspec ion)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity:- gallons Design Flow: gallons/day Alarm present(yes or no). Alarm level: Alarm in working order(yes or no): Date of last purging Comments(condition of alarm and float switches,etc.): s DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert k7lkr L A 1 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER:_L/(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS •• SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued Property Address; twlrW cti r✓! t i4 Q�6 3� owner. A Date of Inspection: p SOIL ABSORPTION SYSTEM(SAS): pocate on site plan,excavation not required) if SAS not located explain why: T3Tp f0 /` b leaching pits,number L leaching CbmftM ter: ("i � � -Po he, leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number; imovativetalternative system TyWname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc) PD✓1 d n ��/ 4/O l✓ /✓1 Ve✓�. . Af Ste, ie iJ 4 CESSPOOLS: cesspool must be pumped as part of in spection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level Of Wilding,condition of vegetation,etc.): C i page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: )9 a .A;Ask c`1— /� O� h r✓i• e Od 6 3�-- Dsate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including des to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. G � 43 - 0 t eat _ 3J , /V - 3� Page lhof11 • a OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimad) prcqwxty Address: a 7q Stu krw - �I Gh ow /•ner: 40t D•gte of Inspection: SIZ'K EXAM sicnz 3uO'm water Check cellar Shallow wells Estimated depth to ground water IT feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record N checked;date of design plan reviewed: 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) Accessed USGS databasaexplain: To f You mustlescribe how you established the hi all water elevation: a /Vo S. A#' i... . vP de I ® 04 .0 � r < < 00010 /4 I� 0000 �t 1 t9 OQ p U % ' ' �� S�(lPrc.��o� r )- — OWN'OF BARNSTABLE SEWAGE #$ft, C�3 1 170-.25� . VTL.LAGE C e e�U \\ a A j SOR'S MAP & LOT INSTALLER' ® E �.�,� , c� •� �\- \a. '>o SEPTIC TANK CAPACITY p p o LEACHING FACILITY:(type) (size) \O O 0 NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER -BUILDER OR OWNER �,.���� ' S o\� o�S O DATE PERMIT ISSUED: j DATE .COMPLIANCE ISSUED: %VARIANCE GRANTED:GRANTED: Yes No k 3v 2 3"` No. ::.1.03`� Flea.....��.` ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF (HEALTH + to—w w.............OF....... Appliration for Uhip uttl Workii Cnom rWiun Prruti# Application is hereby made for a Permit to Constructor Repair ( ) an Individual Sewage Disposal y S ..at.L. .... % .. ---:-------- ,1 . t- --. 2� : ............... --.... ocation- ss Lot No. C . ... .. .. ..:.. ' c� ............... .........• .. >" ........�.�._._... Owner d - a �.�. . . ....... ........................... ..... ._...... ...,�....... . ................ Installer Address t Type of Building Size Lot_.__. �. ._Sq. feet.... U a Dwelling—No. of Bedrooms_..........._:2o.........__---••-•--.Expansion Attic ( ) Garbage Grinder (/` a Other—Type of Building ........._....._............ No j�of� persons_..... ........._............ Showers ( ) — Cafeteria ( ) Otherxtures .................................. �F 6VC....._....._..._.-•-----.......:...._._..................._...._. ..... --.........._.. Design Flow.--_-_..._ __- ....-•--•----_---..__ ]lons er r da Total d�ilow._..._._... �-�.D............ lons.lr W �..._©. P PQ� P� Y WSeptic Tank—Liquid'capacityUOn.gallons Length_ E? .lam_.. Width;_il .:.._ Diameter________________ Depth.. .(b. x Disposal Trench—No..................... Width_._:._�...._._..._ Total Length...._......._ Total leaching area ......_......sq. ft. Seepage Pit No._..._... .- Diameter_.__.._ .__ Depth below inlet....... �� 3 P� �---�---•-` •- p �------. Total leaching area.�.....C..�...sq. ft. Z Other Distribution box (, x Dosing tank Percolation Test Result Performed by...__.�E........ 11�9 ...-......=. Date._...� ?..�.. Test Pit No. 1_!Gc_ ..____minutes per inch Depth of Test Pit... Depth to ground water.... l?_... rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... _-. 0 Description of Soil....0.64 ......... J - A tY .. U .............................................._.._............-•----•---••-....................- •�( . .. . ....... .............................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... _..._... ............ Agreement The undersigned. agre to all gall the foredescribed Individual Se a Disposal Sy stem in accordance with the provisions of TI':L: 5 of the State Sanitary Coo T undersi f t er agrees not to place the system in operation until a Certificate of Compliance has been i§S e b of J�� Signed............ .... Application A roved B 6� at 717- P,PY :.... �/ . ................ De Application Disapproved for the following reasons:.............._............................................_.......-........................................ .. ....... -•---•----•-•-•--•-•••...........................................................-............................................... Date ..... .. .!.`o ..__.... Issued---------------- ........._...:.............. -Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF....... .o '?.1... f LE.................... Appliratiun for Disposal Works TonstrWiutt Ilrrtni# Sy Application is hereby made for a Permit to Construct ).for Repair ( ) an Individual Sewage Disposal Sy at• / 1 i J Location-Address ' 1--------------------------- �o Lot No. ----•�--•- ........... :: . .,?..�........-'.�f _ � v / I�//Y at ........................ --.. W Owner ddreis� ............. ...•--•-•----------.---•----------------- :-----•-•••r•--•,--•••-•--.......y_ .......... M Installer Address (� ••- Q7i 111,111, Type of Building Size Lot-.-....._r........�. r.»Sq. feet U Dwell. No. of Bedrooms............. ...._..Ex Expansion Attic a Dwelling -•-••--••••.•--•-•-• p ( ) Garbage Grinder (T�� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ----------------•-----•••••..--•- �. . ilv Design Flow....--....0•-, �---.-- i_.......----gallons per person per day. Total daily flow............. .. ......._......gallons.(( W �-�'-----------. WSeptic Tank—Liquid capacity 0-gallons Length.©a_ ,._. Width;.�:-I Diameter................ Depth..., ._(0 x Disposal Trench—No. .................... Width...........-........ Total Length.......... Total leaching area....................sq. ft. 3 Seepage Pit No.........1........... Diameter.......-.... Depth below inlet.......( 1...... Total leaching area_2 Q.!_.l...sq. ft. z r Other Distribution box , Dosing tank ( ) O / ....�. `�%s.111t .f�_ Date._.....,..._/ /Percolation Test Results_ Performed by.. ................ ......, 1r-a,� �/'.�---__ Test Pit No. L L-...minutes per inch Depth of Test Pit...�__�''�k?i .. Depth to ground water.C tyV*C rX. Test Pit No. 2.....0..........minutes per inch Depth of Test Pit.................... Depth to ground water............--_-.-.._... a _.... ............................... C .... .............•--- -�---......... O Description of Soil... � �..._ �_ . f�l� � t�IC�`y' . --- ------------------------•--•------.......------.......•--••----..... . �f;tw.Al -- � U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ......................................... -'' ------•---•------ -•----....----•---------------------------------------------------- •-•-•-----------•----•--••---..................... Agreement: The undersigned agrl—t 1 1 the foredescribed Individual Sewage Disposal System in accordance with the provisions of LITLZ 5 of the State Sanitary Code��heutidersign d/f�u her agrees not to place the system in operation until a Certificate of Compliance has been isssuf d by the board�f H/e�alth. Signed.......... /i/ ;% � .. ................................................. .., Application Approved BY ................................................. i Date Application Disapproved for the following reasons------------------•----••--------•-•-------------------...._.....----•---••----.................................. ....................•..••......................•••....-----................................................._....•-----•-•-----.............................._...........----.....Date............» Permit No.......... ••.•-...6—� ! �2.._..... Issued-----------•--•••............... ...._... •--•--•---• -_ Date . ----- -- ----_•---------- - --- -- ---------- .--- u.._...... .. _.. «..w. .� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /`/ / � Trr#if irate of f omplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (—)or Repaired ( ) by........ , ;� �-.... .............. ..............._ ;: .............................. ..................................•........................................ .... Instal at.. �� ........_ 'e 1),/ k'0 ............................. :............_......_.......................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No... _` ...... "7.... dated.......(./ *!- �'.._._.._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. DATE....................•/ 1)727e/<f �......--- ......._. Inspector- .. .....-• -- -------------------- THE ................. COMMONWEALTH OF.MASSACHUSETTS ' BOARD OF HEALTH � ��/��1 '........................ No......................: Fzz........................ �,- Dispo�� u o Tunstrur#iun Orruti# Permission is hereby granted........ �.. -•-•-------••-----•-•---•.............................................•---............................ to Construct or Repair �j �nd�vlid Dis t Sys -� ---7...•. ---••....................... . ... -- _ - - - ..................................................No.... � Street as shown on the application for Disposal Works Construction Permit ................................. »DATE...... Board of Health �2 _. _:. t• • i SECTION SEWAGE s skLl Il1�E`TT SEPTIC TANK— Tjl ,.p..BOX — S —LEACH LZV 44 /T h - TOP F JY.4C.(MSL); ..Z...OF t/eTO W" Ra • ,r WASHED STONE IN• OUT. t G I IN• OUT• k SEPTIC SZL1=l TANKP� -ELEV. ELEV: ELEV. ENV. TM ELEV. ELEV. Am tZe - ;. � WA�.SHED STONE g6� TEST HOLE LOG # d �7v, 2.s rIK�a►� 0 By TEST DATE�d WITNESS 3 BEDROOM HOUSE ', �✓ ^sF TES DESIGN T.H: r 1 T.H. * 2 ELEV: .S ELEV. NO G DISPOSER `' DISPOSER Lc >6• PEFtC RATE 2 MIN/IN. 3G ,3<vll 5l� �' �2�2 FLOW RATE 3_.aO1cAL./PAY) SEPTIC TANK 3 30. ('r REO'DSEPTIC TANK SIZE LEACH FACILITY 49� F1 E SIDE WALL 1077G ��•S (�'Sj = 37��O.G/D. G 67 BOTTOM /Z�ZTT= ,3 ,�,pl �'3 G/D: Q , TOTAL Zo l , I 5� _ 27� T (�. 2.5 USE: �lL LEACHING iao U r F,FF rJiAM x WATER ENCOUNTERED _. -°-• : . . :. � - - � `: aI of - .�p� NO`MS: 'IUNLESS OTHERWISE NOTED) $� hE�� " �0 nA 1k'/06V'1:2 F ? / 1.DATUM(MSL) TAKEN FROM `"' QUADRANGLE MAP 2:MUNICIPAL WATER AVAILABLE ' 3.PIPE PITCH:'A-PER FOOT�� // ��H.:OF 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO• S.MIN.,GROUNO COVER OVER ALL SEWAGE FACILITIES:(1)FT. .�Q APNE: 14 i 6:PIPE JOINTS SHALL BE-MADE WATERTIGHT 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. R r!'A _ �P`�N OF 9SITE PLAN STATE ENVIRONMENTAL CODE TITLES" _ - ARN_E `y\ 8. T�-it's pc�lir_.) FQL v�.,O'il7�c.7 -XJCIC o..�L�c a...•v ��-1�xJr..0 /�/_'_ ��.. _ E _ - - y - _ �-� LOCUS' L 17 -S I�UJ`�eN�T ROAD. _.... ►-roe- �E uD PaZ '�tzoZ��C �.uG �z-A�.ve� C.� �` t' O.' . .A„ MASS REG.PROFESSIONAL ENGINEER J \a'., t? `,�` P 14 .�v' 1 REF: II0 3 Y - WOW,I Cope eIYgifteefring ��. ` �+' PREPARED FOR: CIVIL ENGINEERS' BOARD OF HEALTH REG.LAND SURVEYOR $GALE _ SO CONTOURS. (EXISTING)..... APPROVED DATE _. MAMA LANDSURVEYORS ,a I O ATE '✓ �4 L/�� (PROPOSED)-O-O-O-O- - ��+'��� r . 3 i _ >, <z� A :SECTION . � WAG �,: lkK <I- .. .. f". ...• "�"BOX- / - -SEPTIC TANK - S LEACH - - TO��Q,,F.F i - s/.�fl MSL)• ..2"OF 1111TO Ye": . - ... . . / WASHED STONE , (.+ 6 ` IN - OUT INS +.i OUT• IN . SEPTICG TANK Z �/ ELEV. ELEV. ELEV.' ELEV. Iw # ELEV. ELEV. WASHED STONE TEST HOLE LOG : -Pii-SO 17v, TEST BY L' I��a rl• �ot,l Lo I� - n• _ ST �` WITNESS' t TEST DATE Io19 1 Lf BEDROOM HOUSE DESIGN 3 . T.Hi �►. 1 T.H. 2 -_y[ ELEV. ELEV. L 2 DISPOSER DISPOSER L104 PERC RATE MIWIN. 310�1 50 S lr 1 FLOW RATE3_jp(GAL.�DAY) - SEPTIC TANK - 1 S p REQ'D SEPTIC TANK SIZE LEACH FACILITY � &. ? F SIDE WALL.. �<S) 377 fl.G/D. k Z6 BOTTOM ..�z1Z 7T=SZo,3,_.tj,O) TOTAL 20! , USE: LEACHING r` J WATER ENCOUNTERED a / f=� I — 20� 1c)I NOTES: (UNLESS•OTHERWISE NOTED) i.DATUM IMSU TAKEN FROM .f/tGfr QUADRANGLE MAP 2.`MUNICIPALWATER " jT AVAILABLE 3.PIPE P1TCHt R"PER FOOT 7 0 OF 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- —_—_44 S.M1N.,GROUNDCOVER OVER ALL SEWAGE FACILITIES:_ (2)FT. { ApNF - 6:PIPE JOINTS SHALL BE MADE WATERTIGHT t OF Mq% c "`A 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MAW. ISITE PLAN t STATE ENVIRONMENTAL CODE TITLES 1 RNE fy�y\ 8. T�1t� Pal.,—� FToG 7p'.D7+��cD wo'tJC �.�e_`C J .t� �+-LO�J�'t> ( 4 / !1 i LOCUS: 11 OT '�,E LJ 5BD r=a� '�CO.'!'.-.LT`f l_<.�1C: �ra.✓��tita: ':. .6 �<':,�•A in ._ - -.. _ . REG.PROFESSIONAL ENGINEER - 1 REF•. tF I/j6-ao, - ;�y��,, :• -' ---- -- dow/I CRpe ellg��Ie�r��I� r "r+' PREPARED FOR: CIVIL ENGINEERS LAND SURVEYORS & BOARD OF HEALTH �� mmal!SL REG.LAND SURVEYOR SCALE CONTOURS �PROPOSEO)-O—O—O—O— APPROVED DATE � �� ^"A '' G/ - _ ATE ACCESS COVERS MUST BE WITHIN INSPECTION 9- MINIMUM. 6. OF FINISH GRAD f INVERT ELEVATIONS : DESIGN CR I TER I A . GENERAL NOTES : PORT 3 ' MAXIMUM COVER FIRST 2' TO INVERT OUT SEPTIC TANK: 99. IS DESIGN FLOW: BE LEVEL MIN 2- OF PEASTONE INVERT IN DIST. BOX: 98.97 3 BEDROOMS AT 1 /0 G. P.D. PER I . THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION OR FILTER FABRIC INVERT OUT DIST. BOX: 98. 8 BEDROOM EQUALS 330 G. P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4• D14M PIP 10• 20 3/4- - 11/2- DIA. INVERT /N LEACH CHAMBER: 98.4 99. 15 12 - %0 DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: 96.4 NO GARBAGE GRINDER 2. VERTICAL DATUM lS ASSUMED. FOR BENCH MARKS Y S SET. SEE SITE PLAN. BAFFLE 98.97 ° �' 96 4 ADJUSTED GROUND WATER: N/A 3 INFILTRATOR 3050"S OBSERVED GROUND WATER: NIA SEP TIC TANK REQUIRED EX/STINGV6" OUTLET 330 G. P.D. X 200% - 660 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND D-BOX W/4*1 STONE AROUND BOTTOM OF TEST HOLE s1: 89.5 SEPTIC TANK PROVIDED: I000 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL 12 "� x 29 " I x 2"d SEPTIC TANKCRUSHED STONE OR CONFORM TO MASS. D.E. P. TITLE 5 AND LOCAL COMPACTED BASE SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. DESIGN PERC RATE ( 5 MIN/INCH SOIL TEXTURAL CLASS - l PROFILE .' NOT TO SCALE 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER• EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 3 INFILTRATOR 3050'S W/4'1 STONE AROUND. 4-512 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 512 S.F. x 0. 74 - 378 GPD APPROVED EQUAL. _ w 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SO I L TEST PIT DA TA s PRECAST CONCRETE OR APPROVED POLYETHYLENE. INDICATES _� INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION = OBSERVED TESTE D FOR LEVEL WHEN THERE IS MORE THAN ONE TESTGROUNDWATER OUSTE SHED TP sl Ps12542 TP s2 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. `' s69• HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. 06. 0' l 0/ . 5 0' 101.5/ LOAMY IOYR YR LOAMY I O YR FOR L OCA T/ON OF UNDERGROUND UT I L/T I ES. H SAND 3/4 SAND 3/4� ^ 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE 8' 100.8 6 !01.0 LOAMY IOYR DESIGN ENG/NEER TWO DAYS PRIOR TO CONSTRUCTION CATCH BASIN SAND 5/8 B B LOAMY IOYR SAND 5/8 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE \ LEACH BM-CORNER BULKHEAD RIM-99.33 24. 99. 5 22 99. 7 CONSTRUCTION INSPECTIONS. / PIT EL-103.05 00 ® C / MED-COARSE IOYR C l MED-COARSE IOYR 43 h1 i D-BOX k r ti0 SAND 6/6 SAND 6/6 s NYD '0 EXISTING /�� (V� 44 SEPTIC TANK Q4 P, TP*1� /o 0 NO WATER NO WATER /44' 89. 5 120' 91.5 N O! �m.��� DATE: APRIL 30. 2009A. i TEST BY: STEPHEN HAAS 3 INFILTRATOR 3050'S o �lA�tg M` W/4' STONE AROUND 0 WITNESSED BY: DAVIS STANTON AD 0 O PERC RATE: ( 2 M/N/I NCHja ��� �(T o LOT /9 16184 + S.F. +� SEEN / C S YS TEM DES i O/V 279 SKCJ/VKNE T ROAD . MA / 7CJ . P.4 RCE-L 256 114 RNS TA $ L E ( CENTERV LE ) "A PREPARED F_OR 2�z LEGEND S C O T T M F R ,4 /V K �C T .3 OLD Y,4 R MO U T H ROAD H Y.4 NN / S Mil 0,2(501 m� � CB CONCRETE BOUND -W'- WATER L !NE LOCUS O HYDRANT S CA L E : / 2 0 "A Y 1 2 0 0 9 A Z -G OVER HEAD WIRES GAS L pyW- 0EAGI- E SURVEY I NG I NC srov�-y m � L1GHT POST _ � _ 923 Rou t 6A y Po -E- UNDERGROUND ELECTRIC LINE - Y a rmo u t h p a r t MA 02675 T- UNDERGROUND TELEPHONE L /NE / ��i//it/�i ` 11��� ( 5 O 8 ) 3 6 2-8 1 3 2 -CTV- UNDERGROUND CABL EV I S ION L I NE �� /��� \ ( 5 O 8 ) A-3 2-5 3 3 3 + 40.4 SPOT ELEVATION �_40 EXISTING CONTOUR t�dl PROPOSED CONTOUR LOCUS MAP 0 %Q 20 40 JOB N0: 09-031 F I El_ D CFW/EEK CALC: SAH/CFW CHECK: CFW DRN: SAH