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Home My WebLink About0029 LEONARD ROAD - Health .2` LeonardStreet Hyannis - ?� A = 268 - 018 -= i ° N �i No. . izoo 3 50 I� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Ti5po5af *pgtem Construction permit Application for a Permit to Construct O Repair Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. q Owner's Name,Addres , nd Te No. Assessor's Map/Parcel 0,6 Installer's Name,Address,and Tel.No. 8• Designer's Name,Address and Tel.No. j�/K`� 1009 v 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by ` Date g ao _O Application Disapproved by: LJ Date for the following reasons Permit No. Date Issued g ^} ^a _.. �.; .. No. Fee .__. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migogar *pAem Cow6tructiott permit Permission is hereby granted to Construct ( ) Repair ( �� Upgrade ( ) Abandon ( ) System located at A prY1—A � eQ , ` V 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. I Provided: Construction must be completed within three years of'the date of thisRperMli. Date r 1 &—d Approved by / ) _. v-• � y„9�•.r.yTVY Tyr}i^V ..wn•`+r.v.. .��, ._.-._4'.=..Y."�: ' )l1;° royls.(..'Ty _ _ . w k . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 1 jl 2pphration for Mi.5pont *p.tem Con.5trUction Permit Application for a Permit to Construct( ) Repair(/) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components pa` l Location Address orFLot No. aq At- Owner's Name,Address%and Te.No. I + V CfXi}ti� Assessor's Map/Parcel S Installer's Name,Address,and Tel.No. 9 , (� Designer's Name,Address and Tel.No. S„i, AA__nn U , V Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( )t Other Fixtures �R Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. , Description of Soil Nature of Repairs or Alterations(Answer when applicable) n , y Date last inspected: Agreement: _ t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a-Certificate of Compliance has been issued by this Board of Health. c� Signed n A. Date x Application Approved by d O r Date g Application Disapproved by: Date for the following reasons Permit No. -AOO Q 3d Date Issued _ .-.---,-}-=.- _—_---_--.----------I---._----._-------- ------------ -- THE COMMONWEALTH OF MASSACHUSETTS ry (� BARNSTABLE, MASSACHUSETTS , �e,S✓5� S Certificate of Compliance ` THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( V)/ Upgraded ( ) Abandoned( )by at has been constructed in accordance ly 00 3 ScI with the provisions of Title 5 and the for Disposal System Construction Permit No. /� � dated Installer_N / j v,2 Y n A: y Designer #bedrooms Approved design flow gpd The issuance o{f-t�hi/s`permit"shall not be construed as a guarantee that the system will f--nunctii jon as designed.(//�f Date 75 /.. ��7� Inspector t/ �TFtE Town of Barnstable Barnstable Regulatory Services Department ' ► p$'�F039 Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 28, 2008 Charles Fisher 29 Leonard Street Hyannisport, MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 29 Leonard Street, Haynnisport MA was last inspected on May 3, 2008,by Michael O'Loughlin, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally.Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The overflow on second cesspool appears to have been never used. Piping should be checked and/or replaced. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BO OF HEALTH 7 oma cKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7774 Q:\SEP'f101-etters Septic Inspection Failures\29 Leonard Street doc 11� J Commonwealth of Massachusetts Title 5 Official Inspection Form n � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Pro�per(nt�y Address ..�— � j,, U�1lMX�.L]� �l A/1 0/1 t� D Owner Owner s Name �� information is required for rCt,• Q Z6 eve page. City/Town State Zip Code Date of Inspection , �./ Inspection results must be submitted on this form. Inspection forms ma,y not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your cursor-do not use the return Name of Inspector ~a key. i Company Name c I L4 YnGt.t/yy Company Address 75 Cit own State Zip r — Code :n:- Telephone Number License Number r 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,in.spection 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 [JJ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspeclori Signature UDate 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.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �— aOwner — n D/�, ►ICJI Owners Name information is I required for _ (g� every page. City/ 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: ❑ lhave 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: 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 I5insp.doc-08M Tide 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 Propert A (dress, 1JJA , Owner Own is Name information is �equired for _ � � �13102 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) . B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): [� broken pipe(s) are replaced [� obstruction is removed ND Explain: JARZ 4't Qr 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 withirri 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. 15insp.doc•08106 Tille 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 3 of 15 1 . Commonwealth of Massachusetts Title 5 Official Inspection Form Sgbsurface Sewage Disposal System Form - Not for Voluntary Assessments Property AddressMIDIfIb f'nk.Qj',, Owner Owner's Name information is r f required for • I JyM_ (�,. r l:3( � 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 a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the 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 ❑ d Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/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: ❑ [d Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ d Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 15insp.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner � Owner's Name information is n _` p f2 required for 0m �_ ,).p 5 1 c� 0' 9 every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes, No ❑ Rf Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 2 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 LJ r 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.' a 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 Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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. 15insp.doc-08/06 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 5 of 15 Com monwealth nwe I a th of Massachusetts Title 5 Officialinspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address — �'� an pn Owner Owner's Name f- information is required for' every.page. City own 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 ❑ Ed Pumping information was provided by the owner, occupant, or Board of Health ❑ E;]( Were any of the system components pumped out in the previous two weeks? ❑ [d Has the system received normal flows in the previous two week period? ❑ d Have large volumes of water been introduced to the system recently or as part of this inspection? 0 LEI Were as built plans of the system obtained and examined? (If they were not available note as N/A) E ❑ Was the facility or dwelling inspected for signs of sewage back up? '' [ ❑ 'Was the site inspected for signs of break out? L✓J ❑ 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: Ej Ed Existing information. For example, a plan at the Board of Health. ❑. d 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)] 15insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sawa ge.Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner C&Ahn O , wner's Name �Q,� �-�� p�'� ( n4 information is r/ �hLQ J 1�ti L1sri]-L' required for every page. CityrTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: —� 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 usa e (gpd)): 9 � ( years, 9 Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available; Last date of occupancy/use: Date Other(describe): 15insp.doc•08M Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Volufkry Assessments Property Address Owner Owners Name information is �^ required for , ,I�.:+, (: �•`l `/�, ,� every page. City State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes [ t�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 R Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: CJ ( n: v ec, .�1Lvt rL D c a L?o� ul�U"L,tA� Were sewage odors detected g to ted when arriving at the site? ❑ Yes No ISinsp.dx•08/OC Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Sub/+s-�urface Sewage Disposal System Form -Not for Voluntary Assessments Property Address r--- C �A d Owner Owner's Name information is 6anAn� �a6y? `r required for every page. Cityfrown State Zip Code Date of Inspection D. System Information y tl n (cont. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,etc.): Septic Tank (locate on site plan): Depth below grade: feet ¢ Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------- ----------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 15insp.doc•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form - Not for Voluntary Assessments t r` Property Ad ress Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D: System Information (cont ) :. Com ments (on pum ping in9 recomme ndations, r nlet and outlet tee or baffle condition, on structural 'in tegrity, ri 9 tY, liquid levels as related to outlet invert, evidence of etc.leakage, : ) Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Dace Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): 151nsp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal g pos System•Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is 7��J�1� � )� ]�required for f 7 , ' 1.�� every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.)Y ( 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps.in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 15tnsp.dx•OW66 This 5 Official Inspection Form:Subsurface Sewage Disposal System-Page r 1 of 15 ,5r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments Property Address O ��-/� p Owner CX � , nT 2,` `"__ •_1(, Owner's Name information is o, required for -/L�UU '1 K� ' O�� 6 rj� 31 �� every page. City/Town State Zip Code Dat onnspection 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: •I ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: [r� 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.): t5msp.doc•08/06 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner. Owner's Name information is �m 16 7� I/LI'— D; �[ -,:1 required for w every page. CityfTown State Zip Code Date of Inspection D. System Information (cost.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ° J-� UJ✓L 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 U?r No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): C 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.): 15insp.doc-O&W Title 5 Official Inspection Forth: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 d9 �n i pert Address Owner Owners Name information is required for every page. CityfTown 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. W 1 u�� a -73131 a ?,4 15msp•doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address �— i�V 1�1�1[Qly � 111 4 caner Owner's Name information is ^ 3 2 required for 5�C�.��G�� Qcy-(:� ( lDlJ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date`of design plan reviewed: 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: , .�,�► .n�� o, cry . , 15insp.doc-OaM TAIe 5 Official Inspection Forth:Subsurface Sewage Disposal System•page 15 of 15 Town of Barnstable OF THE t0� Regulatory Services BAMS•PABM Thomas F. Geiler, Director T! MASS. g 1639. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER 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 or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations 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 Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASGPTIC\Disclaimer Private Septic Inspecti oils.DOC