HomeMy WebLinkAbout0081 BLUEBERRY HILL ROAD - Health 81 BLUEBERRY HILL RD,
HYA1RNIS
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TOWN OF BARNSTMBLE
LOCkTION Aki rrr SEWAGE #
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I5r�; L
LEACEaNG-FACILITY: (type) • A 7da�6V (size) X
NO.OF BEDROOMS
jai rjER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between fbe:
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/ f leaching facility) / Feet
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' Separation Distance Between the: ,
Maximum,Adjusted Groundwater,Table to the Bottom of Leaching Facility Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
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.
A. General Information
r
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
c
I certify that I have personally inspected the sewage disposal system at this address and that=1he
information reported below is true, accurate and complete as of the time of the iO'spection Tfie insfiStion
was performed based on my training and experience in the proper function and Mbi!ntenancaf on e
sewage disposal systems. I am a DEP approved system inspector pursuant to.$ection T5:340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails �
03
❑ Needs Further Evaluation by the Local Approving Authority ` 1-
3-10-10
Inspector's gnature 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.
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Dis al System-Page 1 of
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank,as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution .box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
--
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
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 watei
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water'
supply well.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has aseptic tank and SAS and the SAS is less than.100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"* This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the 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 '/ 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.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
a
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No r
❑ ® 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 CM 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`fires or"no to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to,any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document•03108 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M y 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
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)]
l
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
Number of current residents: 1
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 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-9-10
D ate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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:
Last date of occupancy/use: Date
Other(describe):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
General Information
Pumping Records:
p 9
Source of information: Not since new
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
12-2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
ti Depth below grade: 24"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade:. - 18"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
• years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1500 gal
Sludge depth:
12"
Distance from top.of sludge to bottom of outlet tee or baffle
20"
Scum thickness 0
Distance from top of scum to top:of outlet tee or baffle
6" "
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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.):
Tight or Holding Tank (tank must Lie pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
,M 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert I 1 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level.
Pump Chamber.(locate on site plan): .t
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is
required for y H annis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
❑ leaching pits number:
® leaching chambers number:
Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Infiltrators in good working order with,no sign of back-up into d-box or surrounding stone.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of 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.):
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 official document•03/01, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
'wM 81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
C,GY-
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a iL`7
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t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
81 Blueberry Hill Rd
Property Address
Alice Kaltschmidt
Owner Owner's Name
information is required for Hyannis MA 02601 3-9-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope ?
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
r
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
k
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
O
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COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601 C l
Name of Owner NICHOLS C/O DONNA SHULTZE
Address of Owner: 3860 FALMOUTH RD.MARSTONS MILLS MA.026366
Date of Inspection: 10/4/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 608-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
X Fails
t_
Inspector's Signature: Date: 1015/00
The System Inspector shall s mit a-copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If t e system,is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate;regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,,
inspection does not imply any warranty or ghuarantee of the longevity of the septic system and any of its component's useful life."
- THE SYSTEM FAILS TITLE V INSPECTION.THE OVERFLOW CESSPOOL IS PAST THE EFFECTIVE DEPTH OF LEACHING,AT THE TIME OF
THE INSPECTION THE LIQUID LEVEL IN THE OVERFLOW CESSPOOL WAS OVER THE PIPE.
~t.
revised 9/2/98 Pane 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 1014100
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
d
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure
is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved
by the Board of Health.
nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
nLa The system*required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if.(with approval of the Board of Health):
_broken pipe(s)are replaced
obstruction is removed
t
revised 9/2/98 Y Paoe 2 of 11
k�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 10/4/00
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM I.-
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) 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 AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary
to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance n(a (approximation not valid).
3) OTHER
n/a
Art
revised 9/2/98 Pape 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 1014/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
X I have determined that one-'Pr more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a.
_ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large,systems in addition to the criteria above:
The system serves a facility with,atdesign flow of 10,000 gpd or.greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
Yes No �y
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply
well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of
the Department for further information.
it
revised 912198 Paae 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner: NICHOLS C/O DONNA SHULTZE
Date of Inspection: 10/4100
J y
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
i`
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
S
,i4 of?inq Pnnrn 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 10/4100
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):0
Total DESIGN flow: 220 gpd
Number of current residents:1
Garbage grinder(yes or no): NO
Laundry(separate system)(yes or no):,NO If yes,separate inspection required
Laundry system inspected(yes or no NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: nla
COMM ERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped h/a.gallons
Reason for pumping:n/a r
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1964
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 1014100
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 4"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 5'X 5'BLOCK CEESPOOL"
Sludge depth: 6"
Distance from top of sludge to botto&of outlet tee or baffle: 28"
Scum thickness: 2" 1 1,
Distance from top of scum to top of outlet tee or baffle: 0"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
THE SYSTEM FAILS,THE OVERFLOW CESSPOOL IS PAST THE EFFECTIVE DEPTH OF LEACHING.THE LIQUID LEVEL IS OVER TEE.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
n/a
revised 9/2/98 Paae 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 BLUEBERRY-HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 1014100
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: nla
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:NIA Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
nla
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
4
i.
revised 912/98 Paoe 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 1014/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (1)5'X 5'BLOCK CESSPOOL
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE SYSTEM FAILS TITLE V INSPECTION.THE OVERFLOW CESSPOOL IS FULL OVER PIPE,THE PIT HAS NO EFFECTIVE LEACHING LEFT.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla :,
J
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2198 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 10/4/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n a�
O
revised 9/2/98 Paae 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 BLUEBERRY HILL RD HYANNIS, MA 02601
Name of Owner NICHOLS C/O DONNA SHULTZE
Date of Inspection: 10/4/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
revised 9/2/98 Paoe 11 of 11
No. Gl `r / Fee 2�.0-7
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
1'
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for �Digoal *proem Con5truction Permit
Application for a Permit to Construct( )Repair( ✓Upgrade( )Abandon( ) ($Complete System O Individual Components
~' Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel :�� ,O? it
Inst Name,Address,and/Tf I.,No. Designer's Name,Address and Tel.No.
St o v a 5 �27.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3� gallons per day. Calculated daily flow, gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ` s m Sip��l te.�— Type of S.A.S. XA i, Lad&-ul 17(eT-, 0
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) A. Si(�l f d?j�,W.`�y„�9 TRye c_
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 Q
Signed Date
Application Approved b DateP
Application Disapproved for the following reasons
r .
Permit No. Z lJ�,O _iF Date Issued
TOWN OF BARNSTABLE '
LOCATION , U SEWAGE #
VILLAGE ASS R'S MAP & LOT
42�y j INSTALLER'S NAME&PHONE NO.
t
SEPTIC,TANK CAPACITY r S C St
LEACHING FACILITY: (rypep�,JD(—Tir--, UV S
(size) 1 t
710�j�
NO. OF BEDROOMS_ _
BUILDER OR OWNER 1
PERMITDATE: 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
i
Furnished by
�i 0
O
17 11
�.
� t
No. tooge 7110, Fee 6`L7
i
; THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
YYe
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pprication for Mie;paal 6petem Construction Permit
Application for a Permit to Construct( )Repair( ✓)Upgrade( )Abandon( ) XComplete System ❑Individual Components
Location Address or Lot No. U —r✓ui— �` Owner's Name,Address and Tel.No.
Assessor's Map/Parcel -2,,� O? - V
lnstaHp,r_'5 Name,Address,andiTgl.No. Designer's Name,Address and Tel.No.
�l`j
Type of Building: f`
,r)° elling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
,- 0Other Type of Building No.of Persons Showers( ) Cafeteria( )
4 E Other Fixtures
h' n Design Flow gallons per day. Calculated daily flow �C( gallons.
Plan Date Number of sheets Revision Date
i Title
Size of Septic Tank l <472 S Type of S.A.S. urArc c ;t -',( Tec+T-,tr�
Description of Soil yAy,idz
V �cl
Nature of Repairs or Alterations(Answer when applicable)__p T A. S i { �2% �,In`!<f 'L�i✓L f(�1�
�, C t 1 ") t�-.-,,�'i 'Z'-o'cti(!'f/��, C� I L S{ �
purr
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been-issued--by-thisBoar ealth.
Signed /''' Date
Application Approved by Date /siz!zs'—
Application Disapproved for the following reasons x
W
Permit No. C t'Zt CJ ''0;;7,0 ems. Date Issued 11of
�x
----.------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CE_ , that the On-site.Sewage-Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by
at ,�� `,�u,, - .\ N IV At TMia has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction ermit N ated
Installer Designer
The issuance of this p 4 shall not be construed as a guarantee that the sys will function as de igned.�
Date Inspector Q' l�l i _
r'
e \
———————————————————————————————————————
04? Fee
TH ,.,COMMONWEALTH OF MASSACHUSETTS
71
PUBLIC 1- _j . ;H DIVISION - BARNSTABLES MASSACHUSETTS
Migpogal *p5tem Construction Permit
Permission is hereby granted to Construct( )Repair( -)Upgrade( )Abandon\( )
System located at _
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this rmit.
Date: F �r' ''r �=?4 Approved bC—
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
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
rr
I, b , hereby certify that the application for disposal works
construction permit signed by me dated I`—��j-Q , concerning the
property located at � VJ��-r �cu, meets all of the
following criteria:
4,04is failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
V/The soil 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
There 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
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located.with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 15q, Z)
B) G.W..Elevation' (Z +the MAX. High G.W. Adjustment.3L= 3 1
DIFFERENCE BETWEEN A and B.
SIGNED : DATE:
[Please Sketch proposed pl of system <�.
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 system plans.
q:health folder:cent
1 `^`i
V'
.�•_