Loading...
HomeMy WebLinkAbout0115 CHESTNUT STREET - Health 115 Chestnut Street Hyannis ;i r C i Commonwealthf Massachusetts 3D /r 13 7 o Massa h etts ., :a= p Title 5 Official Inspection .dorm l''T,' , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St w Property Address 0.5 Carl Carlson }u� Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 :. page. City/Town State Zip Code Date of Inspection Xu; 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. A. General 'Information 1. Inspector: Shawn_Mcelroy Name of Inspector Upper Cape Septic Service Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the -information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation bythe Local Approving Authority 10*31=17 trispector s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Gv�3dUS Commonwealth`of Massachusetts ' �al Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �N 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form ,i.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational..System will pass with Board of Health approval if pumps/alarms are repaired. ' B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ F 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. t ' 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: El 'Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within'50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I i Commonwealth of Massachusetts .aal j�s Title 5 Official Inspection Form ) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ,a=1 Title 5 Official- Inspection Foam ` .1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town 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 El ❑ 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 "El.,, El Area—'IWPA) or a mapped Zone II of a public water`supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 w - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Commonwealth of Massachusetts la=� Title 5 official Inspection Form 'f4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -;; 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is Hyannis MA 02601 10-31-17 required for 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 s,te 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 informatio,i 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): 3 DESIGN flow based on 310 MAR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Fom �N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St r Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town •. State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)):. . Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2017 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? - 1 ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?. ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 2010 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form ' W-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is Hyannis MA 02601 10-31-17 required for every y ' 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: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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): 18" 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: 1500 gal 12" Sludge depth: t5ins.doc•rev.6/16, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 a e. City/Town State Zip Code Date of Inspection P9 p p D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 3" 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 14" How were dimensions determined? 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 is in good condition with baffles installed and no sign of leakage. Recommend pumping for solids. Grease Trap (locate on site plan): Depth below grade: P feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Vill Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cony) 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: k ❑ 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? El Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 171 Commonwealth of Massachusetts :+ f Title. 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Tile 5 Official , Inspection form -. Subsurface Sewage Disposal System Form :'Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis - t MA 02601 10-31-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-500's ❑ 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.): Leach chambers in good condition and emtpy at inspection with stain line at 12"off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form f � Subsurface Sewage Disposal System Form Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 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.): I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately • f 1 '7 0OqLj 31 PY,4 6 :3 d� ' t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts .a=1 Title 5 Official Inspection Form ++ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Chestnut St Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 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) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 115 Chestnut St ....�- Property Address Carl Carlson Owner Owner's Name information is required for every Hyannis MA 02601 10-31-17 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1�S' GhF�STNt✓T —STiP_,:,�T yAyiy/S 0 a 6 v Owner's Name: D,e. Gs��L .T. GALL S©�/ Owner's Address .53 9 �/,�FL�/@5"CAI 'O,e/V,E;* Date of Inspection: Name of Inspector:(please print) Donald W. Moncevicz, P.E. CiYil ;Engineer Company Name: 40-Pond Street Mailing Address: West. Dennis, MA 02670 Telephone Number: 4n, '08 3q 4 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the i nformation-reported below is true,accurate and complete as of the time of the inspection.The inspection was perfo4-, na based my training and experience in the proper function and.maintenance of on site sewage disposal systeiF am a REP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes O Conditionally Passes Needs Further Evaluation by the Local Approving Author Fails Inspector's Signature. .U. Date: B The system inspector shall submit a copy of this inspection report to the.Approving Authority and 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. e Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C*XiC r/1V r A44 0260! Owner: /E'. A J. �I.CSON Date of Inspection:l. G�A�11�3 _.2�7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete.aR of Section D A. System Passes: I have not found any information which indicates that any ofthe 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 Conditionally Passes: ne or more system components as described in the"Conditional Pass"section need to be replaced or repaired. a system,upon completion of the replacement or repair,as approved by the Board of Health,will pass:: Answer yes,no or of determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is me 1 and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial* ltration or exfiltration or tank failure is imminent. System will pass nspet ;if the existing tank is replaced with a co lying septic tank as approved by the Board of Health. *A metal septic tank will pass inspec ' n if it is structurally sound,not Jeakingand.if Certificate of Compliance indicating that the tank is less than 20 ye s olc is available. ND explain: Observation of sewage backup or breakout high static water level in-the.thstri{uti .box a to brnkenor:;i. obstructed pipe(s)or due to a broken;settled.or uneven on box.System will pass inspection if(with appi•ovaf of Board of Health): brokenpipe(s).are rep d obstruction is zemoved distributipnb "islomiedsa. ND explain: The system required pumping more-than 41finesa year-due to broken or structed pipe(s).The system will pass inspection if(with approval of the Board of Health): brokecrpipe(:s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113"CPiEI S7'NU T .STie Owner: j),e, Date of Inspection: .2-.ZLc9o7 C. Furth Evaluation is Required by the Board of Health: Condition exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect blic health, safety or the environment. 1. System will pass ess Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functio ' g in a manner which will protect public health,safety and the environment: Cesspool or privy is wit ' 50 feet of a surface water _ Cesspool or privy is within 0 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 s tem 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 surfac water supply or tributary to a surface water supply. The syst has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system ha a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a se tic tank and SAS and the SAS is less than 100 feet but 50 feet or more froth a private water supply well* Method used to determine distance **This system passes if the well ater analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic comp ds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen an itrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of t analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART_A CERTIFICATION{hued) Property Address _S"T/�,�, —7 HYAvSv /s: �%lq o z 60/ Owner: Date of Inspection: L G,iz'/Nl�je Z--Z,20077 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for All inspect: Yes No _✓Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped O . _✓ 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 SO 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.th.e...well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failum..critem- . are triggered.A copy of the analysis must be-attached to this farm.] Al D (Yes/No)The system fails.I have determined that one' ' .ure ofthi above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact theBmd of Health to determine what will be necessary to correct the failure. E. arge Systems: To be sidered a large system the system.mvst serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indic either"yes"or"no"to each of the following: (The following crite ' apply to large systemxjnadditimtothe_,ai1cM*2bayc) . yes no the system is within 40 et of a surface drinking water supply — the system is within 200 feet of a 'butary to a surface drinking water supply the system is located in a nitrogerrsensitive (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 onsidered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or opera of any large system considered a significant threat under Section E or failed under Section D shall upgrade the em in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the De ent. y 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: -�.e. GgR� .T (jsgkl S©N Date of Inspection: 4E�� ..2 , -.4519'7 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 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? fHave 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? _V/' _ 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? 7,-1AGHMXAJ7 . The size and location of the Soil Absorption System(-AS)on the site has been determined based on: Yes no✓ _ Existing information. a plan at the Board of Health a,n d/ Gon "���h a s Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] b f 5 Page 6 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 .- SYSTEM IlWORl IATION Property Address: //-5 Gf/i�sT�vuT ,sT,e,�,E7" A41199, m 2 6 m Owner: ,U.e, Cose.c. T GAje.ksOrV Date of Inspection: AD-1C-X1VZRPEX1._ .2 2 2,"7 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): /-/ _Number of bedrooms(actual) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms). 'A'y rjal�yli S . Number of current residents: O Does residence have a garbage grinder(yes or no)://0 Is laundry on a separate sewage system(yes or no):/V0 [if yes separate inspection required] Laundry system inspected(yes or no):_ / / Seasonal use:(yes or no):/t!O _LctST z �crrs vs�O_ Water meter readings,if available(last 2 y s usage(gp Bd)): / in" S. Sump pump(yes or no): ar s.�al/ rain in usern�n �vr. Last date of occupancy: 11 MERCIAL/INDUSTRIAL Type o blishment: Design flow ed on 310 CMR 15.203): gpd Basis of design (seats/persons/sqf,etc.): Grease trap present(y r no):_ Industrial waste holding resent(yes or no):_ Non-sanitary waste discharged t e Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records - Source of information: 3oARp mF Ap4! A,LT'H1 Was system pumped as part of the inspection(yes or no):^/O If yes,volume pumped:_gallons--How.was guantityl)umped.determin_ed? 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/Altemative technology.Attacka copy of the cwent operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Ap roximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at.the site(yes or no):/V O 6 Page 7 of l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:---//$' Gam, 3'Z</617" _= T Owner:Dom, T. GA,P[,Soi�/ Date of Inspection:D.�C.EM.Cd,E/e �2, 2QD 7 BUIL G SEWER(locate on site plan) Depth below gra Materials of constru `on:_cast iron _40 PVC other(explain): Distance from private wa supply well or suction line`. Comments(on condition of ts,venting,evidence of leakage,etc.): SEPTIC TANK: ./ (locate on site plan) /7`4,k /5 /7•, e�e�w grade cv� an i' Iel- r-/SBh Depth below grade: a t? ey Ayl ' apG/ 9ra e, Material of construction: ✓concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) // j Dimensions: 4 /,s''co® �flmn -//ank I -/71A tf G 71 e4ye Sludge depth: ES /2 " Distance from top of sludge to bottom of outlet tee or baffle: 4,1­101---le Scum thickness: 2 �, Distance from top of scum to top of outlet tee or baffle: a 4 Distance from bottom of scum to bottom of outlet tee or baffle /8 How were dimensions determined: ,Comments(on pumping recommendations,inlet and outlet tee or F. //7vei- ondition,structural integrity,liiuid levels as rel ted to.outlet invert,evidence ofleaka e,etc BB�Qrrr_icth ._._v_ /�/o_.- ie n P,ct ce . �i' vi' e! !S �t � "'eahwdler-l-ron? Znnk and a e EASE TRAP:_(locate on site plan) Depth b ow grade: Material o nstruction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of sc to top of outlet tee or baffle: Distance from bottom of se to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommen tions,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of age,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM RART-C SYSTEM INFORMATWW#w m md) Property Address: //.S' Gy,ESTivuT Owner: be, CLg�El FI.E.L�Oti1 Date of Inspection: .22, 2007 GHT or HOLDING TANK: (tank must be pumped attune of inspecti�(la:caft on site plan) Depth b w grade: Material o onstruction: concrete metal fiberglass polyethylene other(explain): . Dimensions: - Capacity: gallons Design Flow: XAlarm* llons/day Alarm present(yes or Alarm level: king carder(yes or no): Date of last pumping: Comments(condition t switches,etc.): DISTRIBUTION BOX:Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Q�� Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidencep. f leakage into or out of bgx,etc.) dx rs ct Zk—'l s n .2 O�� /:s ve _So�'ds M 6 , ' el free m e �. G-� Lvu Y oCtJ M G -m o P P CHAMBER: (locate on site plan) Pumps in rking order(yes or no): Alarms in wo ing order(yes or no): Comments(note ndition of pump chamber,condition of pumps-and appurt=mces,etc.)_ 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: //S G//oeST,UU7— �T T A60�9AIIXIIXI /t// y--z 60/ Owner: _ lie. Gaze-4 .7- 157Ak-,1- -/ Date of Inspection: P--newlg aoOT a SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, xc vation no required) / �e�eve•,ce O/Psi r, O�rawin �/o MvG —/ :11I 7,,�jv � 30 �Z cyil�orl If SAS not located explain why: Type leaching pits,number:_ ✓ leaching chambers,number: leaching galleries,number. Teaching trenches,number,length: qr�,� SvrlGP� leaching fields,number,dimensions: overflow cesspool,number: innovative/alterinative system Type/name of technology: Comments(no j�ondition of soil signs of hydraulic failure,levelPf po din5%+,d s 'I,condition of vegetation, etc. . _�� afion Al" .5/ , c.. YE Ale 61a� so%� ,aps/9n G'/racv���,G �rin� SLI.S /s _3W"/00 SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number d configuration: Depth=top liquid to inlet invert: Depth of solids er: Depth of scum lave . _ Dimensions of cesspoo . Materials of construction: Indication of groundwater in Z�gr no): Continents(note condition of soi of hydraulic failure,level of ponding,condition of vegetation;etc.): P (Iocate on site plan) Materials o onstruction: Dimensions: Depth of solids: Comments(note condit of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: //.5' G .FSrNuT �Tje,C,�'T Owner: � GA,eL. . G'A.��.—smAj Date of Inspection: I �^my SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includinglies to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ,eve.► ,es��i,�a' _ ..0�5 , /d L�a,,,s—p-,'1• 1�TJp^+ . �c/�,c1 ���l� !d _ �I. �q. I1 +�.��I i "1pj ' DtJ.SIc CDIe o�/�.84 �' JV 1 �-3.7 rG'" S,�'r�7�✓+e, �tis� x��.�s7' Goy�� lam!-��'R� 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: //S' ��,gz57-Azu7- sTie,�,ET Owner: Date of Inspection:. �,�G��✓I/ /2 ���_2'=7_'07 SITE EXAM ✓Slope ✓Surface water ✓Check cellar Shallow wells l-Gct r c�v! /-5- Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ✓Accessed USGSdatabasl i e-exp n: z lV � 3.0 /.S o�s�r�RT/�/I w�74� 4dJv � �-If 8 �C� . You must descri a ow you established t e high ground water elev tion: o� Tc� �v. e r A- -2cno2.. /VO w #- n ccv re D '4 v .s'G S q.,nls v2 , ar f e'ea I&n aoArpPrOSC, h�o. A 11 , title 5 . 'Dtic SYN. em. W t Your Septic System: A Reference Guide for Homeowners Caring for Your Septic System The accumulated solids in the bottom of the septic tank should be pumped out every three to five years to prolong the life of your system. Septic systems must be maintained regularly to stay working. Neglect or abuse of your septic system can cause it to fail. Failing septic systems can • cause a serious health threat to your family and neighbors, • degrade the environment, especially lakes, streams and groundwater, reduce the value of your property, • be very expensive to repair, • and, put thousand of water supply users at risk if you live in a public water supply watershed and fail to maintain your system. Be alert to these warning signs of a failing system: sewage surfacing over the drainfield (especially after storms), • sewage back-ups in the house, • lush, green growth over the drainfield, • slow draining toilets or drains, • sewage odors. Y r. p If,i�t SEVd Cjz r`i �" r Y Fr � r' 5c n $uln �r {2i ,U. , �i ffti c::tr ited ente !ford house astemn—tf r goes to d stabution box�nd drain fi&10 �sF:�st�wrtt�r Tips to Avoid Trouble DO have your tank pumped out and system inspected every 3 to 5 years by a licensed septic contractor(listed in the yellow pages). DO keep a record of pumping, inspections, and other maintenance. Use the back page of this brochure to record maintenance dates. DO practice water conservation. Repair dripping faucets and leaking toilets, run washing machines and dishwashers only when full, avoid long showers, and use water-saving features in faucets, shower heads and toilets. DO learn the location of your septic system and drainfield. Keep a sketch of it handy for service visits. If your system has a flow diversion valve, learn its location, and turn it once a year. Flow diverters can add many years to the life of your system. DO divert roof drains and surface water from driveways and hillsides away from the septic system. Keep sump pumps and house footing drains away from the septic system as well. DO take leftover hazardous household chemicals to your approved hazardous waste collection center for disposal. Use bleach, disinfectants, and drain and toilet bowl cleaners sparingly and in accordance with product labels. DON'T allow anyone to drive or park over any part of the system. The area over the drainfield should be left undisturbed with only a mowed grass cover. Roots from nearby trees or shrubs may clog and damage your drain lines. DON'T make or allow repairs to yojr septic system without obtaining the required health department permit. Use professional licensed septic contractors when needed. DON'T use commercial septic tank. additives. These products usually do not help and some may hurt your system in the long run. DON'T use your toilet as a trash can by dumping nondegradables down your toilet or drains. Also, don't poison your septic system and the groundwater by pouring harmful chemicals down the drain. They can kill the beneficial bacteria that treat your wastewater. Keep the following materials out of your septic system: NONDEGRADABLE& grease, disposable diapers, plastics, etc. POISONS: gasoline, oil, paint, paint thinner, pesticides, antifreeze, etc. Septic System Explained Septic systems are individual wastewater treatment systems that use the soil to treat small wastewater flows, usually from individual homes. They are typically used in rural or large lot settings where centralized wastewater treatment is impractical. There are many types of septic systems in use today. While all septic systems are individually designed for each site, most septic systems are based on the same principles. A Conventional SO*system i A Conventional Septic System A septic system consists of a septic tank, a distribution box and a drainfield, all connected by pipes, called conveyance lines. Your septic system treats your household wastewater by temporarily holding it in the septic tank where heavy solids and lighter scum are allowed to separate from the wastewater. This separation process is known as primary treatment. The solids stored in the tank are decomposed by bacteria and later removed, along with the lighter scum, by a professional septic tank pumper. After partially treated wastewater leaves the tank, it flows into a distribution box, which separates this flow evenly into a network of drainfield trenches. Drainage holes at the bottom of each line allow the wastewater to drain into gravel trenches for temporary storage. This effluent then slowly seeps into the subsurface soil where it is further treated and purified (secondary treatment). A properly functioning septic system does not pollute the groundwater. For More Information A videotape version of this brochure, also entitled "Your Septic System: A Guide for Homeowners," is available through the EPA Small Flows Clearinghouse. Call 1-800-624-8301. For more information about maintenance or inspection of your septic system, contact your local board of health or the Department of Environmental Protection: Central Regional Office (508) 792-7650 Northeast Reaional Office (978) 6617677 Southeast Regional Office (508) 946-2700 Western Regional Office (413) 784-1100 Boston Office (617) 292-5673 Town of Barnstable Op 1HE Tp� y� ti* Regulatory Services BARNSTABLE Thomas F. Geiler, Director MASS. 9$prF163.A`�g Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. f TO l~� N x BLS 10-3/-l7 pp u �. S1s1�Vi�G1E�' t6c!A'A'ION 9 SsEssows vix .ab �►n s � i+ga.>? ox STAL' ' ll S-NAME �gloldE NO ` slrc xr c,PAcrrr I5� � » o I RNiHTt�A' _. GC�1 "1I.TR►Z�lCE DATir, ... Sepre uott �seatt�c: etvreen die Max'l MUM' l�l)uStetl Grautsc Water'C'a to Pew Iva9i y�ptir Supply U�u91;w�cl t.east�ng�?acriatyi' ►y Vrolls ax4st a�,nitc�ae..wltlti,n�Qt)fe�C ogtos�cEu9�g fticibty) :'.. �rec�9. :_. l±cl { cyf /et�and aad 1.eaeltlntt l:acidl¢y(lf:iu�y wetlands e9sc tvithitt 300 fl, f loaaliing Nurrl3bad tay � H } a ' I No. ��-�`-'� V c� f r Fee 51101 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppiication for Misspozat 6potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(VAbandon( ) V/C mplete System ❑Individual Components Location Address or Lot No. //5 0HjGS7"Vr S3" Owner's Name,Address and Teel,�`1g. ot Assessor'sMap/Parcel J I � /L �R/la Installer's Name,Address,and el.No. (��, -7740—404W Designer's Name,Address and Tel.No. Donald W. MonCeviCZ, P.E. / Civil Engineer i kd r r yd}P_M®r✓T'/# Al a ®2 ro y 3 40 Pond Street; �P g/� Dr�srGaf West Dennis, MA 02670 e of Building: - Dwelling; No.of Bedrooms Ae4e .4 Lot Size o•2 "-€t. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures y�eat�1 Design Flow 110 gallons per;ap. Calculated daily flow ® gallons. Plan Date Ava 30. --1®02- Number of sheets / Revision Date Title .j G -2 Size of Septic Tank _619L9 GSA,o Type of S.A.S. AA74W,01GFV—TJQ0RS ftJ Description of Soil 1:i?= ujAJ49 /1,/10• Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board alth Signed Date 3® 1P0 Application Approved by 01• S Date `Z Application Disapproved for the following reasons Permit No. __2 Date Issued 3 ,...,- ,:n.,,«-_......._n.-...--....'et---'•-� ....,,..,,o...-,�-.-..•r.+..-�.w �..:w--.s.;....-..gir,.--wr-..n..�_.-.it*r.:.wwra-•--�=.+..-:.-�w -r...-,-�.a.,,.a,:.-�-. .,,,.r.-a�^r.-..--..-, .--". - -.._ ... - V M No. c � - � _ � ` Fee J 0. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ,, .. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS y ZippYtcatton for Mi#oo.5al braem Conotruction ijermit A lication for a Permit to Construct t pp ( . )Repair( )Upgrade(Abandon( ) mplete System El Individual Components Location Address or Lot No. //f Cif/AV rovt pr X ' Owner's Name,Address and Tel-No Assessor's Map/Parcel a•� 1 �^S®N '� g Installer's Name,Address,and el.No. Ow-) Designer's Name,Address and Tel.No. rdWAJ . y w ' r ,Type of Building. pg.Sl 6M Dwelling ,#*�,No.of Bedrooms��.�¢, Lot Size+©• egft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /" r+DOM1 Design Flow //0 gallons perday. Calculated daily flow • 14 D gall Ins._ Plan Date Am6 .3o, ,%oo2., Number of sheets Revision Date Title kopaswp /rawy .S d (4{ FI - -2 CD .� Size of Septic Tank .10 0 .1040 GAS., Type of S.A.S. D/ tJ.tS$7 4J .,n� L"�.it Description of Soil „S11;L� Sl / jNic Ale. /1'1C"'/ !�k�S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: M 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 Cer[ifi- cate of Compliance has been is ed by this Board Health Signed Date 6UA430. Application Approved by . 'i . c_ ` Date r_ i C n Application Disapproved for the following reasons Permit No-- � Date Issued � ��` ��P�----_---- -- —�— --- I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certifirate of Comphance THIS IS TO CERTIFY,that the On-site Sewage Disposal,System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at `✓ •S�' ,f7. 14"Nif has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No._2 CIJ2 - -2 dated 9 I % Installer Designer The issuance of thistpe it shall not be construed as a guarantee that the sy�tem will f nction a d igned. Date ! U?- Inspector `F , � �✓ 0� S L �l W ---------------------------------- �,/� 0 CV No. -`��..�L.- ram- Fee �4 f r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mt5po5al *p5tem Con5truurtion Vermtt Permission is hereby granted to Construct( )Repair( )Upgrade f(V )Abandon( ) System located at #)" 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:Construction must a co pleted within three years of the date of thi /e Date: 49 Approved by / 7 l/ VI Health Complaints 12-Apr-02 r:, e Time: 9:25:00 AM Date: 2/26/2002 Complaint Number: 3285 Referred To: EDWARD BARRY Taken By: FLORENCE SMITH Complaint Type: CHAPTER II HOUSING Article X Detail: Business Name: Number: 115 Street:_Chestnut_StreetD Village: HYANNIS Assessors Map_Parcel: 1 I' 2 y I� !i, Town of Barnstable oFt r Regulatory Services Thomas F.Geiler,Director BARNST"LE, _ Public Health Division �`bp �639• `�� Thomas McKean Director lED MA'S A � . 200 Main Street, Hyannis,MA 02601 Office: 508-862-464.4 Fax: 508-790-6304 March 6 20 02 Mr.Margel V.Carlson 539 Jefferson Drive Paloalto, CA.94303 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00 STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 115 Chestnut St.Hyannis MA was inspected on February 26, . 2002 by Edward F Barry Health Inspector for the Town of Barnstable because of a complaint.The following violations of 105 CMR 410.00,State Sanitary Code II,Minimum Standards of Fitness for Human Habitation were observed: 410-500 The windowpanes in the kitchen and bathroom are broken. The bedroom windows and the bathroom window do not open. Some of the storm windows do not open or close tightly. The rear inside door has no doorknob and no catch. .410-351 The kitchen faucet constantly drips when the faucet is shut off. The toilet does not always flush each time. The wash water from the washing machine.is pumped out the cellar window on to the lawn 410-351. There is no electrical wall outlet in the basement for the washing machine and dryer—an extension cord is used to connect to an outlet across the room. 410-482 There are no smoke detectors in the house. 410-253 The light fixture in the hallway is inoperative and the electric wall outlet in the kitchen is not working. 410-280 The bathroom ceiling vent is not vented to the outside. 410-481 The property is not posted with a 20 sq inch sign bearing the name,address and telephone number of owner. You are also directed to correct the remaining above listed violations within fourteen(14))days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven(7) days after the date order is received. However,this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non-criminal citations of$40.00 for the first violation and$15.00 f6r each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKe an Director of Public Health CC:Carol Noucher 15 Chestnut St. Hyannis;MA.02601 Q/HealthiVpfiles/Orderlet/Carlson/fs FORM30 HAW HOBBS&WARREN M THE COMMONWEALTH OF MASSACHUSETTS � BOARD OF HEALTH CITY/TOWN b DEPARTMENT ADDRESS TELEPHONE M ' Address- +`"'✓ f G fitr ,q' '`a foccupant� Floor Apartment No, -_ _— No. of Occupants— No. of Habitable Rooms_ No.Sleeping Rooms_� No. dwelling or rooming units- "' No.Stories Name and address of owner- r__ t ` '� a� :�-'� 91✓ ,✓� `s'+5✓� s r �i^d? A' �e .a'1 .Tl • r Remarks Reg. Vio. Out Bld s.: Fences: � '� .�t. Garbage and Rubbish r Containers:ll%lej , r. z4;_9 Drainage p�' ✓. �E,. � '7". 'r {"?" '- Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst' lZ x r 7"t4.?% "4 , r. Hall, Floor,Wall,Ceilin �,r, -j. /,�� r� :%a Hall Li htin : .` : ' a � ,!► s�l-ZY f an d s A' �l NY. . * - Hall Windows'146,Aa HEATING Chimneys: 6�. Central, _0 Y—Q N—, Equip. Repair qjv jP "' M°.!J CAV "` ,-, �4 , 4r-Va TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line:,,'' °r J•a S, ❑ MS ❑ ST ❑ P Waste Line'' ,r 1� s ° 7" � r� rJ�,+~..<- .5` '_ X fit ' f H.W.Tanks Safety and Vent s4. c ELECTRICAL Panels, Meters,Ci.r,; � ,r�y-7 '�`, . ❑ 110 ❑ 220 Fusing,Gmd '4-1,s AMP: Gen. Cond. Distrib. Box: Gen. Basement Wirin DWELLING UNIT=-? Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen r r Bathroom Pantry Den Living Room Bedroom M Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'nj'' Wash Basin, Shower or Tub: i ' : A/V Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted A411 Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR .410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR °�+O,,t' � � TITLE _ A M:, DATE—�` '•� �- TIME .' P.M. A.M. r _- THE NEXT SCHEDULED REINSPECTION P.M. r 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to erdanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to f3ll within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall with n this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quar:tity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of -05 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of pcwdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 103 CMR 410.482. (0) Any of the following conditions which remain unco-rected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or Lathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by'he Board of Health. ,t Town of Barnstable °Ft►�tom, Regulatory Services Thomas F.Geiler,Director anaxsrABM Public Health Division 1KASS. i639• Thomas McKean Director TED �s 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 6,2002 Mr.Margel V. Carlson 539 Jefferson Drive Paloalto,CA. 94303 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,STATE SANITARY CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 115 Chestnut St.Hyannis MA was inspected on February 26, .2002 by Edward F Barry Health Inspector for the Town of Barnstable because of a complaint.The following violations of 105 CMR 410.00,State Sanitary Code H,Minimum Standards of Fitness for Human Habitation were observed: 410-500 The windowpanes in the kitchen and bathroom are broken. The bedroom windows and the bathroom window do not open. Some of the storm windows do not open or close tightly. The rear inside door has no doorknob and no catch. 410-351 The kitchen faucet constantly drips when the faucet is shut off. The toilet does not always flush each time. The wash water from the washing machine.is pumped out the cellar_window on to the lawn 410-351. There is no electrical wall outlet in the basement for the washing machine and dryer—an extension cord is used to connect to an outlet across the room. 410-482 There are no smoke detectors in the house. 410-253 The light fixture in the hallway is inoperative and the electric wall outlet in the kitchen is not working. 410-280 The bathroom ceiling vent is not vented to the outside. 410-481 The property is not posted with a 20 sq inch sign bearing the name,address and telephone number of owner. You are also directed to correct the remaining above listed violations within fourteen(14))days of receipt of this notice. You may.request a hearing if written petition requesting same is received by the Board of Health within seven(7) days after the date order is received. However,this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. j You are also subject to non-criminal citations of$40.00 for the first violation and$15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean Director of Public Health CC:Carol Noucher 15 Chestnut St. Hyannis;MA.02601 Q/HealthWpfiles/Orderlet/Carlson/fs TOWN OF BARNSTABLE LOCATION j/S C 3;r SEWAGE # -zooZ- 38e. VILLAGE ,� .r�wis- ASSESSOR'S MAP & LOT :J INSTALLER'S NAME&PHONE NO. ,a mop. '1rlPro � I z SEPTIC TANK CAPACITY 14ncy GSA LEACHING FACILITY: (type) E/-Soo oft lee y 1* ze)- /I"x 3A-0aP z.' NO.OF BEDROOMS A BUILDER OR OWNER U'cQ�A g y_s-,0 Lse).l PERMITDATE: q - 2°7—0 Z_ COMPLIANCE DATE: /D - 3 - o Z. i Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /y 9 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) P11141 Feet Edge of Wetland and Leaching Facility (If any wetlands exist i within 300 feet of leaching facility) Feet Furnished by I r g . s. MIT 19 To j 1 3s:s- �0 r 2 - 3Z" z- zap 3 - �9' � 8 3- 3J•�/ S— 3J•9 y-_ y7 6 - zS�.z � - s-2•Y s Z3410 3 P Sy ' ZZ oo 6 s � i c -� TOWN OF BARNSTABLE LOCATION 1/.5` SEWAGE # zoo2 - 38z VILLAGE ASSESSOR'S MAP & LOT 0 -I INSTALLER'S NAME&PHONE NO. 9 9P-0 JIyI(` SEPTIC TANK CAPACITY 1-1-01D GS'T' LEACHING FACILITY: (type) ff-S®o c.4 JAW Qut ize) f/ 'X 3,9X 2.- NO. OFBEDRO MS 3 -QgEjJsae yY r: BUILDER OR OWNER -C-F �Ys�.oRLso PERMITDATE: - 2r7--o Z. COMPLIANCE DATE: /b - 3 - a Z- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �' . 9 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 Q 611� t� N I { { 1 1 } I 1 'ZIN 0 G�R�fsF w � w �� o W N N tHWE r Town of Barnstable ', P C/ Department of Regulatory Services BARNBrABLB, • y ' 45 .« Public Health Division Date i639• ♦0 QED MPS�' 200 Main Street,Hyannis MA 02601 Date Schedule Time Fee Pd. L�� Soil Suitability Assessment for Sewage Disposal Performed By:P0061AS-0 14A NCEV/G Z p/V- Witnessed By: . EJr A. MG `OU"A"A .. Location Address Owner's Name YA Af�/ ��� S3?-JEffE�'sory Die. A 1,5 m Address AAA.-o— 7-�. CA Assessor's Map/Parcel:Map/Parcel: g 4� a3 En ineer's Name bona-Ids K'IblonceviCZ, R.E. Q - Civil Engineer f R tACM0CAPX Telephone# 40 Pond Street' NEW CONSTRUCTION REPAIR p q- -West-Dennis; MA 02670 Land Use/� S/�i�/VT'�A� Slopes(%) dXVJrL Surface Stories-- Distances fro : Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) C.RF..srAjUr STREET �0 /oo.GO -/sriwG 77 �� 3y iov.9y Parent material(geologic) A/e9 Wg74I1A Depth to Bedrock Depth to Groundwater: Standing Water in Hole:,6A/4VWJ Weeping from Pit Face eG e,20 M-s•G.S. NyAA+,ws VA .A NA�r�1cs Estimated Seasonal High Groundwater AHA XWA` A9'Tlta. u De �ro � QAr EHG W ` iR I ._:Si n. Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. f Index Well# 2 — Reading Date:✓0 Z Index Well level Adj. ct�_7� Add Groundwater Level ZP ..� 1 ., a .. 9 3� i. " a,�. iM'Y i,k i v➢' d a .j iv i�z i�E l ",. x tri r iy, r a'i syi,!' �.-✓ " T S - ' n�I— .� �• ,t" s,L, ...rr:.._-.?ti...,. .:.�'m-,.a�L,.:-,-,.!;�..a ..,..cs. n. _H: _.a, 0n.._y11 a „i �; 7 , s• ' Observation . Hole# /2 O x `, a: :.,, Time,at 9"' { Depth of Perc ° '" ' ' `- y ,a m Time atIF 'C.:. ♦ R � b t tj r f Start Pre-soak�T�me� w s Time(9 6'") „ • O 1 • End Pre-soak ., Rate I in.'/Inchn Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) / Original: Public Health Division Observation Hole Data To Be Completed on Back ---- t Q:HEALTH/W P/PERCFORM ry � �. �� � t sir,K w. t fi,!i .��v ki V .�..� ..:,: n, �...:: ....2 G�'_... : eu,!s�iPr7 ..Vx..,s�z Lek�:u$.?. ,la_:�.r_ �.... ._.r .._..s .. ... _.._. . . ...... ...... .�. ,...... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA), (Munsell) Mottling Structure,Stones,Boulders. QConsistent %Gravel 8 /O V SkmpA VAM AV GX#t RARC- .2 Oo"4 0#4 „ :- _.... r.zw R�'�d.,..kF .;a..��. .i eii d1��t..a ':�.,..,,,.� ..`� 3�,,,.i '•..,.,.. ^� ... :a .. � ,.,.!x.,,k� ...:. .. .. �.. ....,... a..:;�: Depth from Soil Horizon I Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. [Consistency,%Gravel iy f 1: .^.^.x�— .��. �.:.:........ ......: Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USD4)i (Munsell) Mottling Structure,Stones,Boulders. Consistent %Gravel t Q t i ,, ,.. ,._u... .w i.. ,;.. .k,R,..�!�d.�.. ,,, !a.-.'sst #fi,.�h.�s,? n d�,;.-�•,�, .,. _...5,.�,.,r s o ... .„ .....,-z.r,�,.. :. 5 � �::... ... .....: Depth from Soil Horizon Soil Texture Soil Color Soil Othef Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. [Consistency,%Gravel ` 4 3 n • ' Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No_ Yes t• ' Fes•` y# �' '{M1 `c` `` '"is Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -y_1A If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the require training,expertise and experience described in 310 CMR 15.017. Si,gnatur Date Qr Z002.. Q:HEALTH/WP/PERCFORM J N Sr4N/Ti4/2Y 1�.E.S/Gti/ �.SO/.[. �SO/C'PT/O/�! -.SYST'.�/a•1 ,LE'G.�'N.D �E X/s r Ccw rcwR O /6,,93 Wl.&E X.36. 64) 1I- � c/5T/✓J G SST .E/.,E"�AT/Off/ .40 X /.4 tee. S //© 6AA. ,BR- _ 440 G.� Use / soO �k. SkPTic T�vK. 1 ' � h/-20 G�iGS. .6.4�r�f cN.4M,C�'� P- vy No �•�Vea�.cs,E I><sP�s.�,c , C -5o%- 7�sr Z oc Ar/o" .SB��v/.a� d�3'x F'7S 4 A.3'O �t�00 �. .2 Or srayv.F ccw Fv �� �x/s ri.�G 1/lgr R Li�v, yY - �..F.9CH/NG G/TY 4;06.c9�,FT. Cdi m.'74 G.4k,/ScP. FT 4 4.9 45�44. AAD ©N.S/.AF.S. � All"Im 0M M//,/. .449 C��. \ M"k>4/M u/v% MAX , +, LOCUS k e _ 4 0CAT/OAJ MIAP �{• � /� 2.) /Dd APPRmK. 01) /Y(.4o3, 49 Paec,+ 1. /39 .�,L .39. 7 - l - Y -�f'` C� / 'q ,q w h � "AL•g.vD Cm�,eT /cy327 (4lD -S 29 •wvD 30) Z F)00P Pc)c. 774 122- 1>7rP. 07 99 N► , /'/�o v/p.ff �' .�L EL 6" EL �g/tT. .EL Y• L� �� >t=t o�� , .. 37.62 , 32 37.'/S 36.9/ 37. 37 37. 38, O sEiev.4riav .W-.u. /s A r W .230 ts� ,4woC /,Fc7- /O-6 IP " Z�N0 C. �A/t/S]�..s'l.Ert/T /s "1�''I,6 rsr//I uacEie. , i Gales � M/w. .5' t �-8 = .9,c9 `Y.5' AFL- T�'M CN�"S 7%,/<J T- o 7+C G y 4/^ 9 —7 -�soh d/f --Si o%►vG/k ,, - L N D Inc iG�t T/NG G�6.Ssf�t�.t.. � _ __ ___ _„- • __, ., . ___. __,�.1 -7H- aieA /NG P,e�'P�'tiE'.�'D FmR ci ir.�,ey R.e+ ►r,F,r c�v c y. 't y .4 rrL B h /oYR 7/4 TO ` Q.a/c / ccnr-.•w .s-�. 4—racw,r. ?_. fir"TiQRy CahcsrRucT/o� 7-0 MAWr T/rAX 3 3/o C i1//R /S.O©O) ovvp .t�c,�.�. .�s-ca:u�c..A�►-�cKls. W % mrrmtit, oF• P.�.eC /� '¢ .LO.�w�n �°v`/D S�JE'A A/S'7�I�rE� �►/�iq�S �'1h�FAS. E.L ..��i Z 74/.6 uPGRlADx R. =Twl't 'S hiA4s/N6 Avus 1.4(; l lz 0 � I ( B•�s,EM,ENT � �Lur�,aT/�v6 C.c�/N,ECT/©NS �EI�rGD .1�w/lGl�/1�iy'1�.✓ti/TS, 120— C 6, D157 t/8ur10A4 ,,S c /s A .D.B. -9 y-.20 . WiAT'� Iri J I J l C�w,u�GT/ow 7'WWr FW e l-.-vEA- . C AMMOY7- .4t-t. v"Q-vZ.r PolflLj k b G 7 aunt 6 sc,v O► .. �' ,� i9es'�1 ors" 3 � o i',e:, ���([' .�ARG� OAKS4` DONALD y 3 ��. .� ,._�T;r. � g W. ry v MONCEVICZ a, No.20487�0 `490.� . ,sxPric 7,-w/t Fs iONAU /4 oD. � �\ S¢ <. 6• %OF Miss! DONALD cyG W. SysT-.eAM- /0.83.W-36 do MONCEVICz .S©/,L �-L/•E"u mod.rD f: t A9�FGrsTE�` C f-/.�S T�!U T s T. '"r S�ONA4 AS' 1,10 T.'L> 0 G U.S 7- .3 O. Z D 2 8�/VC/4 MA K TmP mx sTA-Acr •�.� -4D.-42 �-a�uv/s u.ap. G�Y�/N.�/@ �l Pf'.L/G•a1/y T . y tVE'LSo/�/ •�/I� /�'��G�.�. 1/. G�4�f�-SoN "7"' Wj�-C = /N/s . MA ��LO ,4 �-TO G,A,[. /�'o/e/v/.q 9-43 43 2/Q.4 K//N G -- ---