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HomeMy WebLinkAbout0436 BEARSE'S WAY - Health 436 438 BEARSE'S WAY HYANNIS A_ _T292 if" i i I j 1 .I i i a o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 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 A. General Information forms on the ( n computer,use 1. Inspector: I V1 only the tab key p to move your Daniel H. Smith, Jr. cursor-do not Name of Inspector use the return key. Smith Excavating &Septic Services Company Name 43 Mattakeesett Street Company Address Pembroke MA 02359 ... City/Town State Zip Code, 781-294-0650 S13605 ; Telephone Number License Number O C) -M B. Certification I certify that I have personally inspected the sewage disposal system at this addre s and that-the information reported below is true, accurate and complete as of the time of the inspection. The insmction . was performed based on my training and experience in the proper function and maintenance`%f 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 (D-'f -2h 3/21/2013 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•11110 Title 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 436 Bearse's Way Property Address Benjamin Levin Owner Owners Name information is required for Hyannis MA 02601 3/21/2013 every page. City/Town 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: System shows no signs of failure at time of inspection, tank was pumped and cleaned at time of inspection (see attached pictures). **This system is not designed for a garbage grinder, they can cause premature failure, we recommend removing it.** 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 F— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every 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 1/day flow !Sins•11110 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 y 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityrrown 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts ARM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 45.21 gpd 9 ( Y 9 (gpd)): Detail: See attached water use records. Sump pump? ❑ Yes ® No Last date of occupancy: Current 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every 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: None Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? As-Built/Pump Technician Reason for pumping: System due for cleaning/Inspection purposes 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-11/10 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 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Installed approximately 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 10"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.): Septic Tank(locate on site plan): Depth below grade: 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: 5.5'W x 5'D x 10.51 Sludge depth: 6-8 11 t5ins•11/10 Tide 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 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3-6" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 811 How were dimensions determined? Sludge Judge/Steel Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was due for pumping, but shows absolutely no signs of failure at time of inspection. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityfrown 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 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.): D-Box shows no signs of failure at time of inspection (see attached pictures). 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: Approx. 5 ❑ 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. shows no signs of failure at time of inspection by means of inspecting effluent levels in D-Box only(as required by D.E.P.);however, other more intrusive means may be necessary to more accurately inspect S.A.S. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 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•11/10 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 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. CitylTown 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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar i ® Shallow wells i Estimated depth to high ground water: 15+ 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: I established the high ground water elevation mainly from site observation, the basement is dry, the material is coarse sand with no signs of ground water at much lower elevations. I am confident the S.A.S. has ample separation from ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 Bearse's Way Property Address Benjamin Levin Owner Owner's Name information is required for Hyannis MA 02601 3/21/2013 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Date:3/22/2013 I,fter Reading Histont Page 1 of 1 W Customer# 603752-2 N Premise#603752 ^' 0 Service:Water-Regular Metered TRANSACTION INFO co METER R DING ReM Da Smanoe2 Mlk[f �Sp�S �l Read Code R�eadirm cu i Cfl IY� code Trans Date 00 2DI306t-I?12[!t2_'V3 x_ ' ....02tt?31201:3: ,:Ot"`3128736�;.,�..0 27020740. 1 372,..r'r-'- '``S..•...:��..,-4--.:. _:.:e.�: =-- ._,...�,...�-..•....m.--- .- aAo 11/1612012 01 31287367 0 27020740 3 1,367 5 0 REG E R J201204 11125f2012 v, 0 08/16f2012 01 31287367 ' O 2702074D 3 1.362 5 0 REG E R 201203 0812112012 , m 05/1712012 01 31287367 027020740 3 1,357 5 0 REG E R 201202 0512412012 0 02115/2012 01 31287367 0 27020740 3 1,352 5 0 REG E R 201201 02123r2012 w co 11MOM11 01 31287367 0 27020740 3 1,347 0 0 REG E R 201104 11=2011 08116/2011 01 31287387 0 27020740 3 1,347 0 0 REG E R 201103 081=011 0511712011 01 31287367 0 27020740 3 1.347 0 0 _ -- 8_ R - r OTO?12812 REG E R REG 'E .. R.4 .2011 flit `O >3128736_7 .;0 27020740 . 3r"1,347 _ _ _.�- 11f1012010 01 31287367 0 27020740 1 1,339 �fi 0 REG A R 201004 11122f2010 OW012DIO 01 31287367 0 270=740 3 1,333 . 10 0 REG E R 201003 09)W2010 05120f2010 01 31297367 0 27020740 3 1,323 4 0 REG E R 201 OD2 DW2712010 0NIM010 01 31287367 0 27020740 1 1,319 4 0 REG A R 20JO01 02124120/0 11/17/2009 01 31287367 0 27020740 1 1,315 6 0 REG A R 200904 11124/2009 08121/2009 01 31287367 0 270ZD740 1 1.300 6 0 REG, A R 2DOOD3 0910312009 = ON21/2009 01 31287367 027020740 1 1.303 7 0 REG A R 200902 0629rt009 i coo 0211812009 01 31287367 027020740 1 1,296 7 0 REG A R 200901 OVIOR009 1111MOO8 01 31287307 0 27020740 1 1,289 12 0 REG A R 200604 9N19fa008 a REG A R 200803 OBi20/2008 � 08YM20DB 01 31287367 027020740 1 1,277 25 0 m DOW2008 01 31287367 0 27020740 1 1.252 33 0 REG A R 200802 05f192008 y 02120f2009 01 31287367 0 27020740 1 1,219 26 0 REG A R 200801 02rm2ODB { 1111WO07 01 31287367 027020740 1 1,193 25 0 REG A R 200704 1111612007 m$ 08/14/2007 01 31287367 0 27020740 1 1,168 25 0 REG A R 2OD703 08114/2007 05122f2007 01 31287367 0 27020740 1 1,143 18 0 REG A R 200702 05t22J2007 07/1212007 01 31207367 0 27020740 1 1.125 58 0 REG A R 2OD701 02f1212007 11113/2006 01 31287367 0 27020740 1 i,D67 15 0 REG A R 200604 11113@0D6 08f1412006 01 31297367 0 27020740 1 1,052 15 0 REG A R 200M OSf1412006 05(W2006 01 31287367 0 27020740 1 1,037 0 0 REG A R 200802 05"2008 # N O CO O O O O - O u5 i I Co INC No. nu cs���a� s 4 3 6 b ` ROBERT B. OUR NCo,O. IncMAo26a5 GREAT WEMRN RD.-P.O.$0 DATE F NAME 6,2 + STREET CITY C/�r �. to-jai � 'CESSpO TAN S)PUMPED: EXTRA HOOKUP: UNE SNAKED: ��;Y• ;'.RED SERVICE CHARGE �. •ao OUMPFEE:f� CASH aEGD$ TOTALS oo Thistompany w9l not be reVOnsiblg for damage caused by trucks beyond street pavement, °NOT RESPONSIBLE FOR SPRINKLER SYSTEMS' THIS IS YOUR BILL eRADY SUSINLSS FORMS iNG.(979)45e-25N i ards http://www.town.barnstable.ma.us/AssessingOgMdisplay.asp?mappar. - j ---TOWN OFBARNSI'ABLE----......-_-•------------ ---- ` LOCATION jr3,(— j 4�r9-L5_1--S G(/IOy SEWAGE iI/015 FG7/aa VILLAGE J,, --�1/�/ S ASSESSOR'S MAP&PARCEL R761 63G INSTALLERS NAME&PHONE NOARC AK -f SEPTIC TANK CAPACITY O i sJ' S—B d LEACHING FACILITY:(type) NO.OF BEDROOMS OWNER PATE: S t� COMPLIANCE DATE- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fe t Private Water Supply Welland Leeching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wettand and Leaching Facility(ITany wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 1JC_f,Z 13ca= ;L F 1 I ! J A v: s s , 0 I of 1 3/14/2013 12:53'PN M �p� 43 Mattakeesetl Pembroke, .MA 02359 • 781-294.0650 Fax 781.294.0649 Title V Inspection 436 Bearse's Way,Hyannis 3/21/2013 -_ - r �j $4 s: 3 t �, qq .may H1 s3{ Tank Outlet Overview 4IZ r °- 7 +. ` lb 4- -p D-BOX jOWN OF BARNSTABLE LOCATION�3�� �� �'��LrES 4: /p,y SEWAGE VILLAGE , -5 ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.hGG��d ys ~ SEPTIC TANK CAPACITY r / LEACHING FACILITY:(type) NO. OF BEDROOMS OWNER >?&W4040,ATE: S a COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY c; i' B . 13c,� = G2y,s, l" TOWN OF BARNSTABLE C-co LOCATION !J'ect rs 55 4/cz�fe SEWAGE # Z©yo— q e-,;,5� VILLAGE jY!40A1e 11 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. AA L.1�e G 2 S-5- SEPTIC TANK CAPACITY -.rV U f&i, l4 LEACHING FACILITY: (type) 5—i h{i f 4i �Y �51 eyi5(size) / D NO.OF BEDROOMS 4 BUILDER OR OWNER PERMITDATE: 1 C' y C/ COMPLIANCE DATE: ? Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i �� t �r � � � E �` � � � ��o� �r � � , � � � � c �Y y � � ��� f � wooe 1� o 1 No. Fee s^ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 49 Yes _ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for Miow5ar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Add ssZrot N Q Owner's Name,Address and Tel.No. Assessor's 41, C c � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ck e L Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building el No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow !2167 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) lam/EGtI 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 bee ued by th=oar e )l. Sign Date � Application Approved by Date Application Disapproved f r the following reaso s i Permit No. Date Issued Igo. / s `` ..', �1^�+" Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4 a es 0 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS '°3�� T - pplication for Mi.5po!ml *pztem Conttruction Permit x Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components r Location Address or Lot No. ^ _O D Owner's Name,Address and Tel.No. Assessor's N4/F3 I (� Installer's Name,Address,and Tel.No. 4� Designer's Name,Address and Tel.No. ih .. CA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )} Other Type of Building 'u3 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. -' P,lan Date Number of sheets f Revision Date " `11 Title } Size of Septic Tank Type of S.A.S. Description of Soil Y. -Nature of Repairs or Alterations(Answer when applicable) r °. Date last inspected:" s..� i 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 Certifr",', Cate of Compliance has been issued by this Board of Health. Y Signede. Date ej - Application Approved by /I/I l / Dates Application Disapproved f4-the lowing rea n 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( ),Upgraded( ) Abandoned( )by at L has been constructed in,accordance . with the provi ons o the `and e r D misposal yst Construction Permit No. dated Installer A I Designer I J A not a c The iss anc of this permit� s a�l�l onstrued as a guarantee that they tem will functiondesig�efl/dl/ t� Date �� � -Inspector7 / +�' �`! 17 No. ?-4/'�TFT -----------Fee __--V�='`��,� . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mioozat 6p5tem Construction Permit Y�' Permission is h feby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at I 4 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:Constructi n muskbe completed within three years of the date of thi rmit Date: Approved by tip_ TOWN OF BARNSTABLE j L� mil{Ps r LOCATION !J� 5 w a SEWAGE # 2060 VILLAGE hQ N 111,5 ASSESSOR'S MAP & LOT — 0 INSTALLER'S NAME&PHONE NO. A4,4Le L rQ r-!ie ]� � 2 S3<1 SEPTIC TANK CAPACITY r v )) 4_S LEACHING FACILITY: (type) [ Y 1S�oN5'(size) / X I NO. OF BEDROOMS BUILDER OR OWNER i PERMITDATE: " 1 C)- y CJ COMPLIANCE DATE: 7 ' t — V 0 i 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 I i �1, �� des d ! 1/6i99 NOTICE This Form Is To Be Used For the*Repair Of.Failed' Septic Systems Only. t CER=CAT"10N OF SKETCH AYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PER UT (WITHOUT DESIGNED PLANS) L hereby cerdfy that the aoplication for disposal wor's construction pernit sided by the dated ' ( 0-- CO C) cancer ding the property located at ' dears e 5 \,/ez-u meets all of the following criteria: • The failed system is conner ed to a residential dwelling oniv. There are no commercial or business uses associated with the dwellins. • The sail is classined as CLASS I and the pe:coladon rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 fer;of the oromsed sendc system • There are no private wets within 1 0 Per;of the proposed seotic srste:n ; • There is no increase in flow and/or change in use proposed • 7-here are a variances requested or nerded. • The bottom of the proposed leaching famlity-will not be located less than five fert above the ma..dmum adjusted groundwater table elevation. (Adjust the zoundwater table using the:rimptor method when anolicablel • If the S.A.S. will be located wit1h2f0 `erg of any vegetated wetlands. the bottom of the proposed leaching facilicv will not be located!ess than fourteen(1=) Pee;above the rnx�idiused �oundwater table e!evadon, Please complete the following: A) Too of Ground Surace =iPiadon(using GIS infortnadon) C/ B) G.`N. Elevation _the High G:W. Adjustment . _ � 2— DT—FERE`+CE BE FWEEN' a, B SIGNED : —_ D T7-- ed (Sire;ch proposed plan of system on bac'c1. a:heakh raider.c t e-3 � o 6C-,Ck CIL i r • , Town of Barnstable *Ire* BarnstableOFTNE Tph, Regulatory Services o Thomas F. Geiler, Director -umiuCiW Public Health Division * BAMSTABLE, 9 MASS. Thomas McKean, Director 2007 1639. p 3,�A 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 i i September 9, 2008 Paul A Cahoon 264 Bearses Way Hyannis, MA 02601 As of October 1, 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at a64-Bearses Way, Hyannis. y 36/�f 3e Enclosed is an application. Please use a separate application for each &ntal unit you own. Should you need more applications, they are available online at www.town.barnstable.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2008 fees included. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. Timothy B. O'Connell Health Inspector Health Division Direct#508-862-4646 i V 1 CC MMONWEAUM OF MASSACHDS�� EXECUME ® `ICE OF ENvjRoNAm&NTAL FAIRS PROTECTION DFPARTMENT OF ENVIRONMENTAL . ITLE-5. Cnolq.FORM-NOT FOR VOLUNTARY SU13S{TIRF PART A CER' -CATION 1 � -e/3 F 13t 19Cz5 f Property,�:dda�egs_. -�3 (Owner's Dame: A' Ewer's Address: Bate offnspection: S 7 0 nn Flame of Inspector_(plesse print�Y.�E/"/2 c sip•+ �_-qv X, Company Flame: Mailing Address: r ©y 2 /y Telephone Number_ E e- F 7 CEII TIMCATI0N STATEMENT I certify that 1 have personally inspecmd the sewage disposal system at this address and��the information reporUed below is true,accurate and complete as of the time of the mean-The inspecXion waspF rformed based on my training and experience in the proper won and mee of on site sewage disposal sysmc I am a IB£P approved systetu inspector pursuant to se/coon Is—w of Trtle g(310 CMR- S-000)- The system: �/passes conditionally Ids Needs Further Evaleation by the Local Approving AU1110rit° Fails Insvee� s vi to Date: inspector shall copy of this inspecrion report to the Approving�o�'(Board of Heath or DEP)withinTbe system days of completing this inspection.if the system is a sba�a3 system or has a design Sow of 1�000 gpd or greater,the imp==r and the system owner shall submit the report to the appropra to regional oMce of the DEP.The original should be seat.to the system owner and copies sent to the buyer,if applicable,and the agproEzng authority. Notes and Comments *��report only dessta�coudifiams at the fsme of.inspection and under the conditions of use at that time This anspectiora does not address hose the sysaem wM pe�orme im the.futmrir under the wine or different conditions of use. Page 2 of 1 I ` PST A CERTIM. CATION(corninned) Property Addresr- 1-/3 4 l3 F-O'esx S Z-J,O y Owner. /^ A Date oflnspection_ h iom SvmmaTY' Check A. Syste I have not found any information which indicates that any of the figure criteria described in 310 Chra 13303 ar in 310 CMR 15304 exist Amy fOuure criteria not evaluated are indicated below_ Comments: B. System Conditionally P2Wes-- One ormore system comp eats as described" "Conditional Pass"section seed to be replaced or repaired.The system,upon comp] "on ofthe rep ant-or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y )in the for-the following statements If"not determined'please explain. The septic tank is m and o 20 years old"or the septic tank(vbether smetal m-not)is structmrally - unsouod,exhibitsor ex5lttatinra arsas�fin $ SySflemadll pass.insne�iort existing tar&is rep with a camp " g septic tank as.-W.w by sbe mod.aMeaith_ =A metal septi pass inspect - it is stsucturaDy smasd,not leaking and if a Certificate of Compliance indicarin'g-that tank is less than 20 old is available- ND e;m Observation of sewage,bacimp or Qmcrhig)rstaiicw3s_levrlinth—edisuffimtion bnx.due tohmimaor ob cued pipe(s)or dne to a broken,settled smewm tfiswftziou box System-Wffl pass.insp m if(with approval afBoard of Health): broken s are-enticed obstructi is r moved. - distrib ' -]sax is Vim" . ND explain: The sYMM required pumping mom than 4rimes a year due to.baaken or obstructed pipe(s)_The system will pan inspection if(with approval ofthe Board ofHealth): broken pipe(s)are replaced obstruction is removed rTD explain t sge 3 of l 1 ffnC AL INSPEC71T®N FORM m-N(Y C FOR VOT�a Y AS .SNMI7'S SUBSI "ACE SEWAGE DISPOSAL SYSTEM INSPECI'ION FORM PART A CE7 TTT—CAT.F-1'--�!NT(cwntirued) Propes-ty_4ddress: %3 - y 3 r /3 Owner_ -/• Date of inspection: Z 7'le e C- Fur-tber Evaluation k Required by the Board ormf--3th: Conditions east which r equireetralutation b , e Boned of Health in order^�o determine if the system is failing to protect public healtenvirorun g_ System w�pass unles in accordxwm w th 310 CMR 1s303(IXb)that the system is not fnactioniuer ich wi99 protect publiic health,Safety and the environment: Cesspool•or privy et o a surface waterCesspool or privy feet of bordering vegetated wetland ar a salt marsh 2. System will fail unless the Board of Health,(and Public eater Supplier,if any)determiy*+es that the system is functioning in 2 manner that pruto-cm the public he29th,safety and nmeat_ _ The syst a septic tank and sail absorption system(SAS)and the S is wither 100 feet of a surface water supp or tributary to a surface ester supply" _ The system has a s tic tank and SAS and the SAS is within a e 1 of a public water supply_ — The system has a sep tank and SAS and the SAS is " 50 feet of a private water supply well_ _ The system has a septic and SAS and the SAS is than 100 feet but 50 feet or more frotII a private water supply weV _M od used to determine ce '=This system passes if the well analysis, ed at a DEP certified laboratary,fbr coliform bameria and volaffie organic compo in the well is free from pollution from that facility and the presence of ammonia nitrogen and " " gen is equal to or less thaw 5 npm,provided thatno other failure criteria aretrig.-ered.A copy of the ysis must be attached to this form- a. Others page 4 of 1 l SP M p °-IN FOR VO1 ��Y LESS-NMNTS IZ1 Q'URSURFACE SEWS(;F-VJSPOSAL- '- -` PART A 36'--y�� �3c'9455S�i9� Property Address: pwnera �r i i�S / vH Date of�spectton' D. System Falure CrjWria applicable as all systems for ail You mast indicate"Vee ar nap 80 each of the IbROWM9 Yes No Dnepr due to overloaded or cloa��SAS or�°°l _�Ba of sewage into a sy�` of the d or suiface��due to am vverloa or — _�D orp onulOorg of efAueuQ�the surface �o� m clo 1 wed SAS or cio�SAS or�oo on box above optlet ipvert dote overloaded Static liquid level m the cesspool _ ter Ie- is lesstlran'f day how •���in g�4 lanes hY the�lqo T due to clues obsYxsicsed Psis?-�unber Parapmg of times pumped - cesspool or privy is below high groom water elavatiou- ss within 100 feel su orf a rfa=water supply or ar3"'y to a stmFa:e Any P�DII of the SAS, • � �.Any Peron of cesspool or privy water supply- he we}l. i A' supply of a cesspool or privy is a Zone 3 ofp public saps�- Any portion of a cesspool or privy is witltar SU few of a prior than feet f um a private water 1 or is-less-t4ma'100 feet VMU3' / Amy Pvruu°of a cesspoo P� xs system paw if the w�!water a�Y�, fly well with so able roar aand voh�e W-WMic enmpo&uses perFormed at a DEp cec�euD I$bnx s3tvrg,fore efiorm- �1 t � te e*sce.uf anemone ind-ucetes that the w H is free to mum pollution fr m ao otht `4" $ nitrvgeu amd niaram�tr'ogeu��1�ssr� �lam' Ore jiggered.A copy Ome aastys � t�su�-� �) t��.�:�nfthe�p�re ��exist as G (yes/No)The sysflem f l have d owner shQtald cotiracE the t?oa2zl of System described la 310 CMR 15303, rem � - Health to determine whams be- Y E. 1.attge Systems s 101099 gpd to'1S,000 To be considered a lame the sy- ate. gpd- You must indicate either Ca-"Mao-to each of the`-folla naM _ (The following esiterm apply m auk$to the above) yes no Cr water supply .fie system is within 400 dt of a surface - —— the system is eriiitffi 200 of a to a gu�ddking water•SUMIY —— area(Fp4e*im WeIllm d fiction Area-19vpA)or a m-Tred the system'is-located in a Zone II ofa public water suPP ell a �Real,or answered If you have auswet•ed-yes7 to any in Section E the systeun is erConsidered of I�considered a `yes"in Secti=D-sbove•the lard fated The owner or opera r in accordance with 310 Cm si_gmificam they-at under5et✓ti fated er Shalt D*A uPgMdethe system 15304-The system owner should co=ct the a37T�3ft3p Tegionai ou"tce of the Depau==& -Page 5 of I I j�lL INSPF, OIV FORM—?,TOT F OR VOLUNTI AR �I ASS�SI�ElaI'I°S . SUBSUR—FACE 5EVJA_GE 3M.SPOSAL SYST EM I—KEIFECTITON FOB„A PART B �2 C?��1V gS T Property Address: 1/36 ^Y IJ 3,F 6.4 2 S 6S 0-9 Y Al i3 Owner:)Plh_S i vA Date of Inspection: Check if the following have been done I'ou must indicate"yeses'or"no"as to each of the following: Yes No �u - mping information was provided by the owner,occupant,or Board of Health _CWere any ofthe 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 m the system recently or as part of this inspection? z _ Were as built plans ofthe system obtained and examined?(Ifthey were not available note as N/A) _ Was the facility or dwelling izmected for signs of sewage back up Was the site inspected for signs of break out? Were all sSsmm compone=,e-cludmg the SAS,located on site? _ Were the septic tank manholes uncovered_opened,and the interior of the tank inspected for the condition o�the es or tees,material of construction,dimensions,depthbf liquid,depth of sludge and dcoth of scum? Was the faciliry owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? 11re size and location of the Soil Absorlstion System(SAS)on the site has been determined based on: 1 - y no Existing infor ma ion.For exampI a plan at the Board of Health Determined in the field(-rFany of the failure criteria related io Part C is at issue ap-proximation of distance is unac -�prable)(310 CMR 15.302(3)(b)j Page 6 of 11 OMC AL INSPECUON FORM—NOT FOR VOLUWARY ASSESSMENTS SUBS®RPA{Z SEWAGE-DISPOSAI.,S'STEMiNsrm::.Y-O FORM- PART-C SYSTI EM IRFORAIIATION Property Address:f-1341- ,! ' .v,v i s Owner. -,4'/4 S Date of Inspection: ze, FLOW CONDMOM RESIDEi11TIAL Number of bedrooms(design): Iamber of bedrooms(acmal): DESIGN flow based on 3 10 L5.2i13(for eyarngi- 110 gpd x#-of bedmoms): Number of current resided Does residence have a garbage grinder(yes or no): k/ Is bu mdry on a separate selvage system{yes or no): /V(if yes separate-inspection required) Laundry system inspected(yes or no):_ Seasonal use:(yes orno):r Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no)* Last date of occupancy- COAUVEERCMUMUSTRIAL Type of establishment Design flow(based IQ CN[R l5 3): epd Basis of design flow( o gfa;etc.): Grease trap present urn Industrial waste hohdia-tank (yes or no): Nan-sanitary wasted th Tit le tle 5 system(yes or no):— Water meter rea i if 'able: Last date of oc OTHER(describe) GENERAL IN RMT10N Pumping Records Source of information Dias system pumpeTas part of the inspection(yes orno)r Ifyes,volume pumped galIons—How was auwtity pumped. d-.,L- Keason for pumpiag: r tiF-SYST' c tank,distribution box;sou}absorption syste m _Single-cesspool _(Yverflowcesspool- grivy Shared system-(yes orno)GfYes,atta if any} _InnovaMvelAheruanvetechnology.Atmrh:;r miry of the torrent operation and rnamtenance-cone=(to be obtamedfrom system owner) - Tight tank- _Attach a copy of the DEP approval _other(describe): Approximate age of aji compo4ents,date installed(if]mown)and source of information: Were sewage odors detected when arriving at.the site(yes or no): v I ' PiLge7ofII T C . 1 MU , Propaty Addrew:y.30- 927,8E.4 aSES �AY Owner- i As � v Date of lnwedram :> 70 BIDING S£ (lode on sate plan) Deptb below grade: d2/ Arterials of canslracfum: cast Pvc citer(exnlam) Distance from private water supptY will or sucxion 1-MM Comments(on ctmdision of joints,Venting,eviden-ce of leakages etc-): SEMIC TAN.:Zgocae cm site plan) Depth below made: /y / Nia=rrial of construction: ncl metal fiberbass_.polyethylene _ lain la`*.ink is metal list age-_ Is age confirmed by a C_-*tificare of Compliance(yes or no): {adacls a css[y r certificate) Dimensions: /m� S X S� X S ' Sludge dept_ h: Ile, L istmmce from tog of sludg~to bottom of outlet tee or baffle: 3 7 Scmn!biickness: � Distance from top of scum to top of ondevtee or baffle- Distance from bottom of scum to bottarn of antler te<or baffle: 9' $ow were dimensions dArer stied: 1'12 L-AS U e i fc-e ST 1 -16r coummerrrs(an pmmpiqg, Met and outlet tee or baEle cm or..strncru al bjte�s t ,liquid ie:'els e as Telated to outlet ink evid-mim uEkakag�ram): i L, / .✓ /��✓�S'7�A i f �i �ias .✓� lir/97E2T� y T �F " G/�� CREM,ASF?'P-AP. (I on site pl,n) s Depth below grade:_ l.•[wmial of co-m�3+on:_ metal_=itF-bass polyethylene comer (e�Iaia): D"unensintrs Scut thickness: Distance�tog of scam to top _ tee or baffle: D"rstanoe a otn botmm of stamr to bo rn aaf outlet tee css bs�le: �g: ns 3rlut and a�tet'-e or baffle ccrdifim-1,c"-�al��i_1�gald tevN-Is Page 8 of I i ,�7�-TBSURTTACE BY AGE DISPOSAL SYS—TE° ON p.. PART Owner: 9 4t9s G'A bats of moss:_S 7 GET or HOLDING TAW-- (tank Must be =fm]E-Of'SS'P CLlL•--q1(l0-=-m on she pLu; Depth below 1 atE1731 Of ' CCSII '[ e metal fib -PVWE"— 'l0n- offi=T(E=hm): - Dmeasioas Capacity �allDnS Design Flvmr sralkonslda} Alarm present Cycs or 3_ Ahum level: Ahm in crier C or no): Date oflast a- �oinmems DHgxmVn➢lq BUM [L*went must be open ocate on siteplan) Depth of ngrdd lerek above met invert; Q e -- COMM={now if bux is level and disII�or to ondels ecmal•amr widencz of solids caarycver_;mTsvider=of leakagge im or oat of bor,emy L r F A- �� c PUW CRAMMER: (locale cm site plan) �m � or.nar alarms is working order or no} Ceffiments(note dim ben oti f ns aid - - Page 9 of I I Ir Wo'_R WO_L=ARY A 07-FICIAL INSPECT!ON FOR -NOD JRMACE TF7VA�7 D=4,3'947-5 S T-1 7 ART C SYS TERT. i 3741M C'u (continued; Proverty-Address-AY3 6 -Z/-7 S' 15,-A AS g 5 Omer. t-1 9-S Date afhnspertinn: 5- 1? loot Tr—i-red)— SOM ABSORFMONT SYS TEEM�R- If SAS not located-xplait-R�r: Type leaching pits,number -Ieacbjngctrambersuumbrr leacbhig-,pEimies_number- leacbingwmches,number,length: leaching-fields,uamber;dim overflow•aesspool,mmtI er inno * * .Ealladw.-system, e of tecbnology-- ZO—Mmen-ts(note-condition of soil,-signs-af hydrmAicfail-twe,level ofpondin,- damp soil-condition of ve:g-rzazion- etc.): J2 ,3 7e?42 -5'7 0 A 6L 0 V "o A CESSPOOLS: o�lj (cesspool must be p>perr�a�spax;z inspection)tjocale an site plan) Number and on: ,d E� 0 Depth-top of Jiq:Wmd to et in h layer Depth of soli7d-slayer r Depth of scum layer_ f-ce spo Dimensions of cesspo Materials of Indication of dwater in ow(yes or no;con of ' in.of Comments to condition of iL simns of m "I;c 17�E PRT-VY:—(locate on site an). Dimensions: Comments(note onofso an F page 10 of 11 r �rope:-t7 Address- 3 - 40 3�tUc A4S�S *9y / �Y/� e✓.r/tY' Date of Insgect�nm .S a SFM i CH OF SEWAGE D SPOT��'ST-EW Provide a sketch of the sewage diisposal system inchAingties w�leasri rma� rsl- lzmd -? benchmarks_;ocwe aSweM wiYitm•-1 Oil feet"Locate Whese7pt7b3ic watursauubmntem the-buBdiug G/ Cat � O n _ � Iq®T FOR VOIvm Rya for — SEWAGE D � Mqo�O PART C ®I�(cos&ved) : � 3 F i3z n�s,s 09y p"'Op� y s,,,,✓ t J per: Date of 6 sr-rr-.EXAM slq= SM75=VraW '(/o ti E rb�*Caw dt y -SbaIIow welb .N c id c Pst�amed doh m�d��'� pime (cW W aU �Ym a*e� a water e Ob�ame� ,m rmmd-rf�-"dL dM oaf Ptm ' ISO fea kwi Bowdarc a— zoa) Cbecked 10cm2di you�ou*e8 the� e3c�� Yoc mom,de aLOv %s 2 A Gt/ — t f.