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HomeMy WebLinkAbout0667 STRAWBERRY HILL ROAD - Health 667 STRAWBERRY DILL RD. CENTERVILLE A = 249 059 Owrford.. NO. 1521/3 ORA �►'� 10% f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 667 Strawbemy Hill Rd Property Address t BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is Centerville Ma _Q2632 1/15/20 required for every page. City/Town State Zip Code Date of Inspection. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S /4 y stic) on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane VQ Company Address Cotuit Ma 02635 City/Town State Zip Code B+�n 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/15/20 I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. CityfTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 Gallon septic tank as well as a concrete distribution box and 4 Infultrators in stone 2) 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): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): li ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ra Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �n l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 coo, Commonwealth of Massachusetts A Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City[Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage Semi Seasonal 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �x l,� Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped in 2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v � 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Installled 6/1/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sytem is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's in place at time of inspection. Tank is solid with no leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of 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 t5insp.doc•rev.1126/2118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): No signs of back up. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 667 Strawberry Hill Rd u Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville . Ma 02632 1/15/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 Infultrators in stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form z Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of back up into distribution box. System is functioning as designed 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a V � 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,rA Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 6/1/01 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: test hole data on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 1/15/2020 Assessing As-Built Cards TOWN OF BARNSTOLnE LOCATION y S/!A 4-,ler Qy SEWAGE M_2O/^33 y VILLAGE �e"�v7 E4 v/A- ASSESSOR'S MAP&LOT` j -OS- INSTALLER'S NAME&PHONE NO.A2 C P/ e,✓1 T 2 Z E G�, 2 _ SEPTIC TANK CAPACITY O �� I�+'�✓ LEACHING FACILITY:(type) �<//�4.troCJ' (size) 33k /O,7'X e1 NO.OF BEDROOMS BUILDER OR OWNER '09 N au G 46 R PERMITDATE: / d COMPLIANCE DATE: '�—V-O 4 _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 2W feet of leaching facility) Feet Edge of Wetland and Leaching Facility(lf any wetlands exist within 300 feet of leaching facility) Feet Furnished by l� E a.s- 5� ,e vo r D .3 ' ,r- 3 13 sa o y ,T r QC, y ' o.1c s4­0 https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=249059&seq=1 1/2 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 667 Strawberry Hill Rd Property Address BOTSFORD, JEFFREY W& LEILA A Owner Owner's Name information is required for every Centerville Ma 02632 1/15/20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ❑ D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I �s O W O O I � o h N N O StOCd(ADF F£NCF C9 S 83°32'40'F � /18 '.t DEED v 5t't N 37•# Y y G� 2 CONCRETE❑ J w FOUNDATION � SHED Ci W � Q o ^ o w DECK 0 o ND +, ono Q( 26.895 f S.F. A N o N 686�•,o�Fa � TOWN OF BARNSTABLE ZONING ZONE : RD - 1 CERTIFY THAT TO THE BEST OF MY PROFESSIONAL SETBACKS KNOWLEDGE. INFORMATION AND BELIEF THE DWELLING FRONT - JO ' SHOWN HEREON CONFORMS TO THE HORIZONTAL SETBACKS SIDE - Ip ' OF THE ZONING BY-LAW FOR THE RD-I DISTRICT. REAR - l 0 ' WHIIIN(3 s q' N 29869 r' �29�?�.� >y �.Cs`4 '�,7� x�G'2w L'�r.k� �s ',.�:, _ �;• ��,,§'� ,, ct c .�. _ ` �; w_: '' .T `tT �.7�'�: y. �h�. j! ..: s -,` �«;.- Y•-- `�_•..:.� tiJ N.-;:::,..Lx..- .:.= - �' ..,Ff� ...>. W.•t -Y,t.� Nr t f , TOWN QF BARNSTABLE �`../ LOCATION rho 4eIeZ-2-*2Y SEWAGE #-�C©/- a3 5 VILLAGE �c �✓7,C4�✓r / ASSESSOR'S MAP &LOT Zy9 -05 INSTALLER'S NAME&PHONE NO.�2 c�/ ��T 2>-�—/3 G SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 41•✓-//reA ro e-J (size) 3 3 NO.OF BEDRO®MS ..:.�. BUIt:DER OR OWNER'.,.; � PERMITDATE: l COMPLIANCE DATE: --44.0 1 Separation Distance Between the: aximum Adjusted Groundwater'Table tothe M Bottom-.of Leaching Facility , Feet PFivate Water Su I Well Leaching Facility (If any wellsezist - PPy. . ' . on site or within 200 feet of leaching facility) Feet Edge of Wetland.and Leaching Facility.(If any wetlands'exist �' within 300 feeE of leaching facility) Fees Furnished by 4 } N Y / x _-Z-Q- o 3Cz s c 13 ]�cCGc TOWN OF BARNSTABLE LOCATION S f2 A 'r/8�2�2Y ��` l� SEWAGE VILLAGE ���✓� El r��R� ASSESSOR'S MAP&LOT Z119 -dS INSTALLER'S NAME&PHONE NO./7 2 c i-1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 4?4/•vim/r?,.42 e,J' (size) X /® •`TX NO.OF BEDROOMS BUILDER OR OWNER -49 CZ �� G le— PERMITDATE: C COMPLIANCE DATE: G — D l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,31 r No.Zery > Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS ZIppftcation for 30tgpooar *pgtem Conotructton Permit Application for a Permit to Construct( )Repair(grade( )Abandon( ) D Complete System D Individual Components Location Address or Lot No. Owner's Name,Address and Tel No / 6'C S 2 % A.v 4 � L1F !-AA 'l/ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �2CE/6' -7 7-5- -Z Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0 7-o ems- Y " Sro.✓c4 Air o v•. /��• Ci,� E' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i d b s B d o al Sig Date Application Approved by Date Application Disapproved for the following reasons Permit No. Z/U!— 33 Date Issued No. C.d v > Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in comp— PUB\LIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Rpplication for �Diopaal *pztem Construction Permit 9 ;Application for a Permit to Construct( )Repair(grade Abandon( ) ❑Complete System ❑Individual Components / Location Address or Lot No. Owner's Name,Address and Tel No.,/ Assessor's Map/Parcel 2/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. j�2Ctil.,s% -7 7-5— Z Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil: Nature of Repairs or Alterations(Answer when applicable) 3 3 X io Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the.Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Bard o eal �j _ o.. D� Signed �- Date Application Approved by Date Application Disapproved for the following reasons Permit No. Zev " 332 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance ,,,- THIS IS TO CERTIFY, that the On-site Sewage DisQosal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by 142 "A/ � N f� C a f at G 7 s% i� cci d= 2/� <<�✓7 F a been construc in accordance with the provons of Title 5 and the for Disposal System Construction Permit No.�d�"3 dated `�/' Installer /Z e,Al ra ­S' i Designer The issuance of j pe t shall not be construed as a guarantee that the syst ill ctio as desig, Date I� Inspector --------------------------------------- No. Fee 2�/- 3� Sa , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTk -� Migooar *pgtem Congtruction Permit Permission is hereby granted to Con�s�t uct( )Repair(Upgrade( )Abando� � t( ) / System located at G 7 57, 1? 0 £ `2�y �l' �l �� C. E and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru tiolt must be completed within three years of the date of this 't. t Date: G l U Approved by 3 3 X /o.T X T } 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL R W//OK S CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) `7B-FAO�r, hereby certify that the application for disposal works construction permit signed by me dated Zo , concerning the located at b b Si�A w/3��t�P% 11,114J C � R'�1 property � meets all of the following criteria: U *� is failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. <�Thheoil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system here is no increase in flow and/or change in use proposed /. There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the maximum justed groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: Cl A) Top of Ground Surface Elevation(using GI information) S / B) G.W.Elevation +the MAX.High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED : DATE: o D [Please e4prsed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic systemplans. q:health folder:cert t� �, *- COMMONWEALTH OF MASSACHUSETTS t . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMNT OF EMRONMNTAL PROTECTION e MAP PARCEL . OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY SUBSURFACE SEWAGE D ASSES PART IA.SP03AI,SYSTEM FORM / CERTIFICATION Prop"'Wdries: /jai�� Owner's Nama -'2 � P* Owner'sAddrem tier► ,.� e Date of hopedion. o 6 --a Name of Inspector. oop ON� rn MaOin=Address: O Telephone N=ber CERTMCATION STATEMENT I certify that I have peiso�lly inspected the sewa0e disppsat at this below is ulv%aoo=M and oomptete as of ft time of the iuspecYian.The addwss and that the won d ftaininap8�woe is the proper Rrnctian and Dian sine wes based on my ysten °r "to of Titk,3(310 ?Mj 0M), l 'I am a DEP CMR 13.000} The Passes Pa.4ses Fads Neub%dw a*atwn by the l=W App�g A,,,,, Inspector's Signature: Data The"M 1° shall subrint a copy of this or gamer,thethe iinpoctar 0ns m a shared systew� �fh WWI*Moad Health system owner shalt submit the _ 10,000 DEP.The anginal AMU be sent to the system owner and cauthadly- opies�m t �;� t*k and the ap of the provia 8 Notes and Comments ""This report only describes conditions at the time of on time.This Inspection does aot address how the system w� urm the and der the conditions of use at that conditions of use: iWam under the same or diifere,K M Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI �N1'3 PART A ON FORM CERTIFICATION(coadinued) Owner. 3 vt c Date of v Inopec6on sm.. Check AjkC,D or E/AL cromplete an of Section D A. S I have not ibund�r�which that of the 13.303 or in 310(31�IIt 13 304 exist,Any fairs ctaia not am indicated akcds d mtxd in 310 CURCommeatm below iS CandiHonapy Paaeea: One or more system ccanponeU as&=ibed in th,„ .mpaThe system,�CO as cf the�or�°m°qXrov� a by the Bood Of HeOW win 1m cq ,An"'yes►no of not detn (Y,N,ND)m the 1 the farrowing Mkmlats If`bot wed'• . Pie a for the she tanit(whet6pr ar tank meta!or not) zany is ftW 'A metal tanit w�11 bft � i f t is tauh as approve by officaUX Sysk MU Pm won if the g that the tack is less than 20 years old is not leaking and if a CadficM of ND cgLda; ObOtructed a CC or break oat or ldgit 5WW l'vd in the d tnUdon oir 3PP MW dBoard c f Hach): °,segled or uW= � ma pm bon if(w ban due to� o6stroctio kokm x(s)M replaced is msnoved dht ulmdon boat is lev cW Or replimd ND explain: ` The system requaW Pig more than 4 ' Pam inspectiiott if(with approval of the Board of Heal ))th mes a Year due to bmlcea or obsuucted 1iPe(s). hdken pk*s)ace r+epJaced _boa is removed ND explain; i Page 3 of 11 OFnCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECi'TON PART A FORM (' T/IFICATION(contia� P►roperiy Address: ✓ rep Owner. du c(v w 6. - Date of M �- G - Ihtstha Zvah�13 R,�by the Bond of Health. fCaptions MW which: mom the is fading to Prot public health,safely or the Board aiIiplih in order a if the s9s m L sys ftft wig Is �Board of lrealah rdanoe with 310 hwdmft In a maoew��P aft0f A 6v� �13(1�)thaa the smWy and the awhvsmeah _ Cesspool cr privy is withk so ibet of a surtm waft C °0l or pm is wift 30 fat of a bordering veget q, d or a soh marsh systemym nwcMtIo 1RUM of Health(aad PabBr:Wits S ,d N that Prtitects peblk health, dy� y na that the — 71 water has a tack and soil system a 'or fhfry to.a surface water�y (�and �°SAS is within 100 fgd of s — The system has a septic:tank and SAS aad the SAS is vAft a Zane 1 of a ._ The system has a septic tank and SAS Pic�sup*. the SAS is within S0 feet of a The O tem has aseptic tack and SAS and the SAS is left than 100 fM water 1. Pwaoe water supply wdl** �yhod used to deomrioe&sbnae but SO�or more firm a { *'�s9stem passes if the weII water a+dwlah'le or Permed at a DEP iged the that the wan is00�'•for ooliMM oiterb am triggered aP9 ='as eequal to ar less the and aitached to this form, Provided OW no other �. Other; PIp 4 of ll • OFFICIRP'AC,E SEWAGAL INSPECTION FO S�SIIE� NOT FOR VOLIINTARy AS SE POSAL SYSTEM INSPECTION FOSS PART A CERTMCATION(continue FMprt4Owner.z �1 TGG✓ Date a, y YonSmote ��to�a[�" mx Yea No f011O`V1°8�� -- � ofsewap WorryOraye o=pd°�°S d to the die to ovedaaded or* SAS ar �Bt�SA3 ar ceaspM of the gout ar surfaoe R's�s�to an 1 (� h3vel in the man box*"outlet invert due to an ipd S add of ""Y"" cmqw more is�s than 6'below• awe vo o oadad or clogs SAS or times than 4 times in the last�or lame is less Wau K dap Bow �/°fP�wnped_ or due to ciogggl or A(s).Number�—�9 theCMVOOI AM pmtion d mapooj or� feet of a Pdvy is below ab�d water e1 *of sappiy, surface water supply or wry to a Porttm of a 1 of a pui�Wet -- Ap pwd=cf a7 is &et of a private water=pOy well. ar 1�+p�lean than 100 float but supply well will►no aooeptabie water 8matrr than 50 feet fMm a pivate water perfOXIMd at a DIP oar fifl 9 17�L syateas pan"ld the wep pnkwaiver hdkMft that the P L 0rp•fOr colifor=bacteri t and s�Y�, • and,�idxte nit, �b M1 that taciflty and rid ' pounds areA�y d the a�y��to orbe to�fem,d that as other r crtteris (Yea/No)The syshm fdS I have �that one ar H�in 310 m w o win,therefM awss yt y��tart 7U the above � as determine what win �, coract thenowner ShoWd the Board(f To SySi ms: i>Ad• lend a lath system the system most serve a facuitp with a design flow Of 10 You b&,, a dda`YW or"no"to each of the 'W gpd to 14M Mowmg cateu;a"to�systems in addit=to the m•teria above) es no the system is within 400 feet of a sum drun g water supply — — system is within 200 feet of a tr;burary to, aurface dEinidng t the Mp, ?,tee II is lowilm "nitmga Mui*e arcs aaftim Wellhead hoteca.Area_fWA ors mapper If have answered„yam.►� `f YO m boa D above to system has Sdon E the system is coma siquesda f&Ha Tlm �a signifiq� threat �or 13.304.The system owner UM E contact the or ftW w Sechoo D shall u Me system a Ord aYstem considered Ppopiah reOMd�d aeco a eDqmtnft with 310 CUR L1 Paip S of i l OFFICIAL INSYEE,"I'ION FORM—NOT FOR VOLUNT ` SUBSURFACE SEWAGE D ARY DISPOSAL STFM'NSFECTION FORM CHECKMT Pt,►Ad6m COP' Srcw 6 N tee �G Owner: t I �0P-63,,2, Daft athwpec&mG o Chet Tithe&Bowmz have hero done,Yoa mast a Or"Was to each of tha faftowin Yes was prw,ded by the owner,O004M4 or Bmd°f naft Wei oaf ddw systemMMODOMPwVed out intbepmioos two weeb �ft�racdved=fmd Saws in the previous two wmk pem Five large voh mea otwaft been Wmducod to the system ncenty ar as Pa of th s Wens as burn piaos adtbc system obtained ands Was 66hCHitp of dweaWS hapected for sighs of seWalp back up Was the sitehR=W for sib cfbmk ON Were aU systemCOMVOBCmW,uchxrmgthe US,looted on site We= the wpdc tw* of the m�► Mwh"ID°00A' and the ico4 d of&*took for the ae�°f ;�� aaddepth� 00 was the 6CMW owner(and ° scam woe of sobsu twi sewage C smm�own )Provided with on the proper 'le sip aad location��SA Yea no Absuptbe System OLAS)as the site has bees fined mod am Mmmadm For e3MHPk a phn at the Board of fina Maocepta* (3xb)I°i dca related t°P&t C is at issue of distance S Pae6afil OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSXSUUWn SUBSURFACE SEWAGE DISPOSAL SyS�M INSPEt� PART C ON FORM SYSTEM WFORMATION Property Adder cD a tOwner: OwDab ofRZM wcs Number at be* (dedPk Number of be (.-cW* a[ an314C1sklenft 0 132p3(flw 110Wda#of I IMa Islattadry on �� bps ar nok� . L �ar���or nOX� f�f yes separate n mk Xv Sump Eft a noX-" Last date afooa�aoiy;_C'��w� CO USTIM , \ T►pe of c9d2 tww* DcsltD 8ow OMd u®310 CJyR 13.203x o..a Basis of design dow Ny*"Jm dschaqpQ to the P tag data �n�'ifava>Alm. title 3 system 6,� �);_ OccepoWAnc OT11RR(d==ibey, ftwingnmorb CANINAL RMBM nON smmoothfamadm. Reason fw p �" 'was pamped deter TypgAwsn—ysl= — bow sosl abeo�pticaa system —Owe bw cesspool _._.Privy —Saed sysbm(M Of BO)O joug a h°0 �ltochnoIo�y.Attach a copy o f 'on and ---T'gbt tm* _Attach a coP9 of the mp approval woe--hacx(to be —Odler(desmft-); AlD-Idmate a fire of as components,dab od(if lmown)and offiftmadw aCOt7 I— Qp Were sewage odors deWW Ulleu arriving at the site(pes or no):� K i Pap7arli OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ESUMM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEIMO SYSTEM PART C RMATION(oontl� property Aunm57 w Rcli Owner: J3�1 �✓ ' '9` o�t.�,� Daft or BUIWINGSEWER �ske ptan) DqAbdowgradk Material,otconstmcum. � Dhimmkompavatewateimp* ann�40 PVC—0dw O. o�o o n or wou or suction hm enting evidence aatIeaira�e;etc,); SEPTIC TANX- v MWNW ar 00a( ) — — — If tank is metal 1iO 8W'.— Is 4110=finnedby a / x//08pte or Comps(ym or no):_( aDimendout copy of SlndV depth;Disumftm �o scum*kkm= top tobottom afoutlet the or baft Distame fmm top arscom to O ----_top outlet toe ar bare: — Distance ftm bottom of scam to bottom t tee oe�"'� -SC ram/ �wee a�bma°si°°�&Wxubled (m pm#n8 ndet and rbdp as#akdto ou" evidence of tee baffle CO WM waGmal 3 ,,squid kves GREASE TRAP; onDepth below grub. L 9 s lam) Mataw a(con —tee ( 'nww _. —other scumScum ofouM MAN" to 0scnm two Date of>as<pr� bottom tee arbdL—'annuelft(en �_ ---_ mmw as g 0�'�ad oudet tee ar bade cow ft): 8MY,h9polevels Page 8 otF 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSDIMS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C SYSTEM INI�'OItMATION(cam Property Auumm Owner:MZY,44 v` CIADace at y TIGHT or HOLDjNG TAN]�(�most be pumped at time aline aas site plan) cmskwdam _.._cmcrece meth„ Capa�►:_ ne.. Dkesign Floor. , Almon kP v& Dab ofLwpun g Alarm order&a or no). Commeals(oaa of atarm and>�t swicc>�eta): . DIMTRMUTIONBOIL• (ifps be VM400ca,on site plan) DeFth a[Bgmd level above outlet invest Cam nab(lab fiboa b kvd and outlet evideone leakage' ar out of boas et�k of mft cwayove;any evidence of �o x ievr�/, c,,/ L PuNw /j �on sica p Pump inwadgWar(yuatm)c— Ala<ma in woddog.onder(yes ar nor Comments note condioic�a�fpomp m O(pomps and Wwftm3cg4 Pages 9 of l l OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM Him Property Add RMATTON(comti� er Owner: Al c Date othopecdm SOIL ABSORPTION SYSTEM(SAS); (mate on site plan,cmavatimnot neqWred) If SAS net bcated explain why. Type Pkknunibm stde�namba: a' nmmbw. TyW=ma oftechnalw C (mb COKUM afsail'signs of id of dmp=A of CESSPOOLS--&--icessMal nma be pumped as part of inspmxocecase� 3 Pam) Number and cou'suadca Depth— I to �h idler invert a[a[ Materials ctcomacroc�o� Indtcad=of , ar no); COnmuft(�ood�as of mLs;g s of hydraulic mme,L-vd of pmals= t m of vWtat,4'). PRIVY--,e�on site Dfinensiom.- Depth(!solids: Im'e condition'Ofsi �' ps of hy*aW( lei-fd.,condition Qfvegetation,etc.): 9 I paDe 10 et I1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSAWSTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cn*m4 Prep"Addmm (p / owur. dc4 s k/ v ' 01-6 Daftatbupecdoic6 �! S=TCH OF SSWAGs DISPOSAL SYSTEM 'Provide s shekh c(dw semp disposal system bwhxingtks 10 at least two pit rebeooe landmaft or beoehmaft t.ocata an weft within 100 fiat.I.ocata where public water supply cut=thebml&g r du 0 �0 _ pa8e lI atF 11 .0 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIMNIM SUBSURFACE SEWAGE DISPOSAL SYSTM INSPECTION FORM PART C SYSTEM INFORMATION(condauvd) Pr""Addmin Date of 0 Srrs I slope Sa:rfaoe water cdw sbaliow%vita Fabod depth tck gMundwou a fuel Phase indict(clad)aN medm)&used to die the hlo Mmmd waw eta obtained iiam system dedp plans on if checkW date of desip plafa reviewed: ro F Ob oved site(abattin8 progolylobsen-am bole whbin 150 feet of SAS) . 00cted wi lmd Bo dofxeai �ba�ed with 1=9 mwxvato% (aucb docaase�dation) Accessed USGS aalab0. ron: YOU must&scrft how youWidwMhe water devadotox : , ti lG CJ (p• � �^J , �/WOE-✓ V 02 4 — w �•-q" 1 1 1 VJ J o N 1 1 I N 1 1 1 - N Q _ g.p• 22'-A" 3 w JAI. FIX, b�51GN S�p\lV I C�5 Uo 09 PLOr PLAN OF 6615TFAWf3 PTY HILL FOA17 jC,14 51ZE PATE RAWNPY P�VISEP IfV O �j 12 OCt 04 J,13oa0pP 10/30/05 r EEr 10r I. — 1 NOTES: zy-s 1/2" EXI5TINCA INTEPIOF WALL5 SHOWN IN UGHf DASHED LINE5 NEW AND PEMAINING WALL5 SHOWN IN 5OLID MACK LINE5 DEC 5EE 5ECnON DRAWINGS POP CONVUCTION DETAIL5 315 5Q,ET, BEAMS PEPLACING[3EAt?ING WAU.5 SHOWN ON IMPIOP HEADEP PLAN"A5 PHANTOM LINE5 DECK LOWED LEVEL 91'-0l/4" CLINE-DASH-DASH-UNE) 9 (15TEPDOWNFPOM 269/s" UPPED LEVEL) EXISTING HEADED LOAD LEAPING WALL OPENING TO LE PEPLACND s, TO LN PEPLACNn LY LY HEADNP ONLY P05T&LEAM O SNOWED 1ILL I 0 KITCHEN-198 SQ,PT, EN I 2'-s" yvavt exhEz J •J: II Tf?Y-5I 50,P PELACN EX15fING WINDOW 1 ,, 3� WITH NEW DOOPWAY = n LA5EMFNf 5fAIPWAYT conrC oar fO LE PEPLACEI7 Ll =i=-i� 27"X 41" U 40''X 40"HATCH) 13Af1 I-50 SQ,Pt, 1 62"X 30" O ANDLADDEP xk �J __ zp - A Lit- 24 VB" PE MOVE ONE LOUVEP POOP C I 10'-115/ O - � i LOAD LE ING WALL ADD WALL PNMOVE EXISTIN TO 9 LALED LY NEW CONSTPUCTION �— �I ADD POCKET DOOP I NE W CON5VUCfION EXISTING WALLS P05T LEAM -2'-10-I/2"X12'GA13LN-POOPED o I 4'-9"X12'-I I/2"GALLE POOPED WALK-oUf LAY(22 50.Ff) AND ADD WAK OUf LAY L _1 i_ ao cr LEDPOOM AMMON(49 50.FT) I I 45"X 92" �� I I I � N PEMOVE EX151NG WALL A. o IL IIi --- AND PADIATOP AND EXTEND LENGTH OF LNb\00M -- i �© LIVINa/DINING -472 5Q.Ft,� f3EDP00M-182 SQ,Ff, / _____ __ __________- 245/t� / A 41-45/4" Ir-o° 4'-lI/2" 5-Ion/s° LOAD LEAPING WALL TO LE 26v2° zs1/z" �I.00r? pI.AN PEPLACND LY P05f&LNAM CAN'UVM9 fO CAVVY POOH a ro OVNP WALKOUT LAY 5CAl,�; I/ 4 I I - I ',O 1 1 G PEPLACE I PONf POOP AND FI MING 9 53 501 I � WITH INTEPIOP WALL AND 1700PWAY - - u � DOOPSCNNDULN: N (D THEPMA-TPU 5MOOiH 5fAP 590 2-PANEL 2/LITE-3'-O"X 6'-8" (2) THEPMA-TPU CLA551C-CP9f CCP205-2'-8"X 6-8" O ANDEP50N FWG 50681L-5'-O"X 6-8"GLIDING PATIO 1900P WINDOW 5CNEDULE:(A-E-ANDM50N 400 5EPIE5) M P�51GN 5MIC�5 6L52;P.O.-36"W X 23"H-ON 3 © GL42;P.O.-48"W X 2-5"H-QN 1 - 22-41/4" I6-61/4" TITLE COTTALE IZENOVAT1ON5 AT © W12N2842;P.O.- 54-1/8"W X 52-7/8"H-ON 4 6615VAW13EPt;Y HILL POAR CENIUVILLE,MA Q W H20422;P.O.- 51 15/16"W X 52-7/8"H-OrY I POP LE ILA AND JEPP f305FOPD _ AN251:P.O.= 28 1/8"W X 21"N ON 2 SIZE DATE DRAWN BY C u ocr 2004 J.ror5om 1o/REVISED REV 23/05 A Q AND,TM452:P.O.42-1/8"W X 41-1/4"H-OTY 1. MOVING FPOM KITCHEN, SHEET I of I st•-n I�4. s 7 -1 r5 -1 I CC MMOQ y ( y I IL I i '4" •I ! 9 1/4• f y Z 1 l c 22'-41,4• RBR Design Services TITLE 7Ki I i O.A. with bonus room for Jeff 8 Leila Botsford SIZE DATE DRAWN BY REVISED REV w�VJ 1 .0 110CT 2ooa J.Botsford 1 �� w.1Gh\ ���Vr � SHEET 1�of1 �i f N ————————————— 14 M-45' E 28' 90 6D=70 I V-22' A iz N `A,x 12' D iN 0 z F 22 PPv PF516N 5FPVICF5 TITLE PI,O"PLAN OF 667 5TRAW3FFVY HILL FOA0 pO VF5IMNCF OF JEFF & LEILA 130f5FOI?12 SIZE DATE�DRAWN REVISED REV 12 Offor ? os-RN 05 2 SHEET I or I I' s f. t d / 11 1 1 1 1 1 1 1 1 T FlpIIjIjlTIl �izi/Zi I ILI 0 �A5T FLFVA110N 50UTH �LEVA110N M P�516N 5FVVIC�5 TITLE 13LINGALOW-5ME GAPAGE W/PON1,15 DOOM FR JEFF&LEILA 13Of5FORn SIZE DATE DRAWN BV �REVISED REV HEET r �- `\ _ 40PM� ro rlp5r r oop 5morT C7mcf0p N V CV I 6-1 �/4 91/2 z -�1/2" o � MU51C 5T"U1210 z � I , ' MW Z 6 r Z -31/2'I orrice z 6,011 fl P�516N 5MV I C�5 -1 1/2" TITLE PUNCAOW-51'M 6APA61� WITH PONU5 p00M a Mr50NwnH24a2-2 FOP, VF & AMA 13Of5FOpn 2Nn F 00k PLAN - 1 / 411 - 1 ' -011 -101/2'' T'101/21' SIZE DATE DRAWN BY REVISED REV C 11 OCr 2004 J.6off oW 03 a 05 SHEET loll