The URL can be used to link to this page

Home My WebLink About0267 LINCOLN ROAD - Health 267 Lincoln Road Hyannis P, . A = 271 076 r' 1 I i I I D 0 Commonwealth of Massachusetts ° 0 Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rr 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. Inspector Information �/ 14f600 filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Co Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2_ 05/26/2020 Inspector's Slgna ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road V Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: This 5 bedroom home has and H-10 1500 gallon septic tank with an H-10 pump chamber and an H-10 D-Box feeding 3 leaching chambers. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. I *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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ brokenpipe(s) are re laced Y N ND (Explain I p ❑ ❑ ❑ ( p 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 - page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ M Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Ip Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ E Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 598 GPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2019-9600 cubic feet was used and in 2018-7900 cf was used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 267 Lincoln Road Property Address Steven and Joarin Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Per Owner: System was pumped 16 days ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road V -- Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Pemit 12/1/1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 15"feet Material of construction: ❑ cast iron N 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 6„ 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: H-10 1500 gallon Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1" 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 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection D. System (Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I ran the pump and tested the alarm * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts Title 5 official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Comm,onw'eaithi,of Massachusetts r l 1 ►c,o�a�llr �� cti o n Form - raa S'c: =� + x ♦ "«,max + Subsurface Sewage1D,sposal°System ®rm Not for Voluntary Assessments 26.7 Lincoln Road Pro"pertyAdtlress -- -- - S:tevenxand Joann Cushin - er, Owne(s+tJame: tnforrraUon Isi required for every Hyannis MA 02601 05/26/202.0: _ - - page: Citg/Town, State Zip Code Date of Inspeetion'` 6)�:;14-Sketch Of;Sewage.=Dtsposal System: `' t a r Provide a view of'the sewage disposal system,.including ties to at least two permanent reference. landmarks or benchmarks,'Locate all well's within 100 feet. Locate-.where putillc.17 water�supplyNenters the building Check:.one of'the boxes below: ' ° , +, �i {hand sketch,in;fihe area°below .drawirngattached sEparatefy g ., • 1• . 41 v Ar . _ •� IT . ,fit.•„ e. s F'a- + Aft . ., r ''t—;a..i i'f � k , `M^ a � ;..''t•�.,`.�12`^ {'4 r .i • i .. .t t5insp:doC•rev;7I2ti/2078; Title 5,01ficial Inspection Form:Subsurface Sewage Disposal System Page 18;of .v j Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road__ Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form <iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 267 Lincoln Road Property Address Steven and Joann Cushing Owner Owner's Name information is required for every Hyannis MA 02601 05/26/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ,d1 c I�fwfl ------------- Le n �\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RE CEIVED SE2 2003 TOWARNSTABLE TITLES DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION NEAP PARCEL , Property Address: 267 Lincoln Road LOT V � y� Hyannis Owner's Name: Steve Cushing Owner's Address: Date of Inspection: Name of Inspector:(please print) W i 11 i am F._ . Rob i nson Sr. CompanyName: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number:(508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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/,op ection 15.340 of Title 5(310 CMR 15.000). The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: a o Dute: yr� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth-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. Title 5 Inspection Form 6/15/2000 page I r Page 2 of 11 x' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 267 Lincoln Road Hyannis Owner: Steve Cushing Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys `m 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repair .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,c diibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing ta.ik is replaced with a complying septic tank as approved by the Board of Health. •A metal s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating hat the tank is less than 20 years old is available. ND expla' O servation of sewage backup or break out or high static water level in the distribution box due to broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approva of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expla' The s stem required pumping more than 4 times a year due to broken or obstmacd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:-267 Lincoln Road Hyannis Owner; Ing Date of Inspection: C. Further Evaluation is Required by the Board of Health: 12Sy ditions exist which require further evaluation by the Board of Health in order to determine if the system protect public health,safety or the environment. em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the em 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 tern 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 su face water supply or tributary to a surface water supply. The system has a septic.tank and SAS and the SAS is within a Zone I 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 front 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 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 failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: I 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 267 Lincoln Road Hyannis Owner: Steve Cushinct Date of Inspection: a D. System Failure Criteria applicable to all systems: You ust indicate"yes"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I 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%%-A= supply well with no acceptable water quality analysis. (This system passes if(lie 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 (fiat facility and (lie 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.] (Yes/No)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. Large Systems: o be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 g d. Y must indicate either"yes"or"no"to each of the following: (Th following criteria apply to large systems in addition to die criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If of a public water supply well If you have answered"yes"to any question in Section E die system is considered a significant threat,or answered "yes' in Section D above the large system has failed.The varier or operator of any large system considered a sig scant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3 The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 267 Lincoln Road Hyannis Owner: Date of Inspection: �g a Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes _ rr///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? a/_ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? �✓ _ Was the site inspected for signs of break out? L/ Were all system components,excluding the SAS,located on site? _t'/__ 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: Yes...no 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 CUR 15.302(3)(b)] 5 e Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 267 Lincoln Road Hvanni-c; Owner: Steve Date of Inspection: 4.� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.. Number of bedrooms(actual): DESIGN flow based on 310 CNW 15.203(for example: 110 gpd x#of bedrooms): . Number of current residents: 2--- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):/t d [if yes separate inspection required) Laundry system inspected(yes or no): (j e es or no :Seasonal us .(y ) &:-� Water meter readings, if available(last 2 years usage(gpd)): 2 0 01 —1 0,2 2 2 Sump pump(yes or no): 2 0 0 2—1 2,9 3 0 Last date of occupancy: S — COMMERCIAL/I, USTRIAL Type of establishm t: Design flow(base on 310 CMR 15.203): gpd Basis of design fl w(seats/persons/sqft,etc.): Grease trap pres nt(yes or no):_ Industrial wast holding tank present(yes or no):_ Non-sanitary aste discharged to the Title 5 system(yes or no): Water meter eadings,if available: Last date occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as partAt the inspection(yes or no):_ If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for pumping: Te F SYSTEM ptic 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) _Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all component, da e • called(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): L::- v 6 ]'age 7 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_267 Lincoln Road -Hyannis _ Owner: StPVP r,�Shi na Date of Inspection: BUILDING/condliction (locate on site plan) Depth belowMaterials ofion:_cast iron 40 PVC_other(explain): Distance frowater supply well or suction line: Comments( of joints,venting,evidence of leakage,etc.): SEPTIC TANK: '`(locate on site plan) t Depth below grade: I Material of construction: !st"oncrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confumed•by a Certificate of Complinee(yes or no):_(attach a copy of certificate) �c s t Dimensions, Sludge depth:tea— Distance from Mudge to bottom of outlet tee or baffle: P- 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: /� D How were dimensions determined: y Comments(on pumping recommendations,i e and d outlet m l tee or baffle onditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): CREASE TRAP:_(locate on site plan) Depth bel w grade:— Material o construction:_concrete metal fiberglass(explain): __ polyethylene ___outer — Dimension Scum thic ess: Distance fr m top of scum to top of outlet tee or baffle: Distance fir m bottom of scum to bottom-oroutlet tee or baffle: Date of last pumping: Continents on pumping reconunendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of leakage,etc.): 7 Page 8 of l l f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION(continued) Property Address: 267 Li ncol ^Road Hyannis Owner: StQge C rsbi nq Date of Inspection: r— - TIGHT or HOL G TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constru ion: concrete metal fiberglass_polyethylene other(explain): DimensioT(yeor Capacity: gallons Design Flgallons/day Alarm pre : Alarm levarm in working order(yes or no): Date of laCommentor; and float switches,etc.): DISTRIBUTION BOX: (rf pr esent sent 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:/((yvcs cate on site plan) Pumps in working ordr no): Alarms in working orr no): Comments (note condition of pump chamb er,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 267 Lincoln Road IHyannis Owner:St-PVA Mishi ncr Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): 't/(locate on site plan,excavation*not required) If SAS not located explain why: �,l+saChing pits,number:_ leaching chambers,number: leaching galleries,number: 3 leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs.of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPO P S: (cesspool must be pumped as part of inspection)(locate on site Ian) Number an configuration: Depth—top f liquid to inlet invert: Depth of sol ds layer: Depth of sc m layer. Dimensions of cesspool: Materials o construction: Indication o groundwater inflow(yes or no): Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dime' ns: Depth o solids: Comm is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: 267 Lincoln Road Hyannis Owner: Steve Cushing Date of Inspection: '3 . 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. � • t 10 i ,Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 267 Lincoln Road _ Hyannis Owner: Steve Cushing Date of Inspection: 9---6 3 SITE EXAM Slope Surface water Check cellar Shallow wells t Estimated depth to ground water,;?-_S 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: bserved 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: O ' 0 G i> I 11 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Migool 6pgtem Construction i3erntit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. M C.Cv� F� D Owner's Name,Address and Tel.No. �U�� 4/13 L-1 A Assessor's Map/Parcel WIV s � ��1 PA�r�I- 0-76 �, �To nz Installer's Name,Address,and Tel.No. #20,D VW-b Designer's Name,Address and/Tel.No. `50V 702- m&as-ryas IV ius Type of Building: Dwelling No.of Bedrooms Lot Size lTsq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5-/d gallons per day. Calculated daily flow 5-SD gallons. Plan Date 1/�� /71 q'q Number of sheets Revision Date N Title Size of Septic Tank >SOb4L Type of S.A.S. 3 x 6-00 6.4-t— Description of Soil Nature of Repairs or Alterations(Answer when applicable) `� aueva 0ec2 V�, yzi f Pf- L 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 Envi onmental Code and not to place the system in operation until a Certifi- cate a cate of Compliance has been i e by this Board o eal Signed Date Application Approved by Date Application Disapproved for the following reaso _____ X Permit No. Date Issued t •> TMh�d! c <.. ,}` ._ Fee. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC.,HEALTH DIVISION_-TOWN OF BARNSTABLE., MASSACHUSETTS 01pplica'tion for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 2 -7 I m cow FED Owner's Name,Address and Tel.No. ��,Sp q , y/31 Assessor's Map/Parcel " / S I& Jy Z71 P-4al :- 0710 ! -orLtSTOfI c� /Yi Installer's Name,Address,and Tel.No. 47.0,p ZIr- Designer's Name,Address and Teel.No. SP,r4 VS 4P t-L 1e= V A r"E�-s tt4a '8ov '70Z MA•9-STorJS A411 ,S Type of Building: Dwelling No.of Bedrooms Lot.Size �Tsq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures d Design Flow S`�d gallons per day. Calculated daily flow J gallons. Plan Date //8 /7 s Number of sheets 1 Revision Date 64 A Title Size of Septic Tank Sib L Type of S.A.S. .3 x, SOO 6A-4. Ctf.4rr�/3 5 -Description of Soil Nature'of Repairs or Alterations(Answer when applicable) `c, C1l xp > 71 Date last inspected: �"''/['� Agreemept: 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 4Env' nmental Code and not to place the system in operation until a Certifi-cateof Compliance has been ' u by this Board l N. Signed Date ��' 7' Application Approved by ate / Application Disapproved for the following reaso s Permit No. — Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE Y, th t t On-site S wage, i.pos System Constructed( )Repaired( )Upgraded( ) Abando ed( )by 1 at !/ 62 f7 t_ 6 constructed in accordance 4 with the provisions of Title 5 and the for Disposal System oust krion'Permit No J dated Installer Designer , t The issuance of this permit sh 11 Monstrued as a guarantee that the t -will f nction Pdesig_ d/Ah d Date Inspector r i 0 _�N——-- -- ----------- -- __...-. ._ _— No. Fee 1 ~� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 33igpogar *pgtem Congtruction Permit d Permission is hereby g nted to Construct( Re air( Tpn4T:�don( NVA011 � System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons cti mus a completed within three years of the date of m Date: Approvedbyl Wes-- 14 1/' J� - Lo-r 9�3 04 y7/ 7- ` IA De x �!at I3i Im SToN67 AT ON®S - °i,V 14 1100 Get. GAi- -� -2 �I�2°�o9� 'BoTToM S3°1 —OuE7 TO SeWeiL pt pE eLEvArrt c)O �OTA-L �09 CbEArvcic- Foit- RATA ( ki c�chP`t t'u wtP , -7 q -o a��nn -x�s o�✓ P��2b�—�J S� GAD LI. i7, 1 2- y Al�� 21> N A-N a3 is 1 MA — mAP 2-7( PA-m 07 6 1/669 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH A,Y APPLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (W=OUT DESIGNED PLANS) I, JA-M 6� hereby ce:tuy that the application for disposal works construction perl7tit siped by me dated 17'l� concerning the property located at a 67 Li nj eoz-ti1 *AJ 5 meets all of the following criteria: • T"ne failed system is corner ed to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS 1 and the percolation rate is less than or equal to minutes per inch. • There are no we lands within 100 fee;of he proposed septic s✓sern • There are no private wells within 1:0 fe`;of he oroeosed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching faciirr will not be Iccated less than five feet above the rna.dmum adjured groundwater table e'.evauon. (Adjust the groundwater table using the F rimptor me;hcd when applicable] • If the S.A.S. will be located wih:fO fee;of any veze=ced wetlands, the bottom of the proposed (eac ring facility will not be Iccated!ess than feur;een 0-) fee;above the maximum adiured Vroundixater table elevation. Please complete the following: A) Top of Ground Sur.-ace =:evauon(using CIS ink)rmauonl B) G..V. Elevation _the"L--X-High G.W. a.diur=ent. 3,2 = 2S Z D TFEREv CL E E i.V EHN A and E 3 b � sic,ti H) DATE: (Si"Ch pro sea plan of s.sem an bac:c;. a:.`.csith ioldc-;-t i L _ [,Or f3ti' 1 LOT 83 i Sl, I.rII,I ` I I. A QQ t,OT (94 1 `y)( � y O !u•J � � r'��y LOT 85 X11,1Y XONE: '143" This MORTGAGE INSPEUVION P" s' f-or 1y FLOOD ZO1VE. "G'" THE .DISTANCF3 AVD Stt , ON THRS FLAN HHUULU HF, V15RIFIED BY AN IN§TRUMENT SURVEY. TOWN: ....J...15------------ REC:ISTRY OWNER: lANIA�, -At�_Tkt%STEE ------ DEEP REF: _1E`'11,3. 395 _ -_-- BUYER: LLIder /I „1�ILL, 19-1,,-IB DATE, lO,.:ft�,i99 ------- --- PLAN REF; _-56-`��_ �c�-..:_�� ;t_'ALE:]. 8U---I'T. 1 1JER DY CERTIFY TO____ ____ THAT THE HIJILDING PAUL YANKEE SURVEY :,11OWN O__N THIS FLAN IS LOCATED ON 9�H UROLIND AS � A, �� CONSULTANTS SHOWN AND THAT ITS POSITION DOES ___ CONFORM memiffitw W`ij 4pB (STATE 1) TO THE, ZONING LAW SETBACK RRQUIRlE MENT OF THE tin-- s TOWN OF. ...._.._TfYANN_t,S'----------------AND THAT INDUSTRY ROAD IT DOFS_..J O.T. ... LIE WITHIN THE SPECIAL Fi.d.)OD IwAru) MARSTOPS MILLS, MA. 0264n AREA A.' SHOWN ON THE H.U,U, MAP DA'1'L''D_l1;,�9�z__ �t D:i�� I'P l: 42$-0055 r_;50001 .00011 D F' "-5553 11,G�1 ________ THIS FLAN NOT MAIN; FROM AN INSTRUMENT SURVEY 078 . F ER A1. A. MITHEW U NOT TO AF, USED FOR FI NCES HU11,DINO PERMIT~ ETC. ` 1 cry TOWN OF_.iaAN0Wk4Ab ) olb f j LOCATION: VILLAGE• -}i(l�IJ t�i 1 S t, - 1 LOT # : PERMIT # : 9 1 - 7 7 S ! INSTALLER' S NAME• a1 i Mi 1-4 di.-"- c_- INSTALLER' S PHONE # : "/ 24, v LEACHING FACILITY: (type) 6AC LdAeid (size) NO. OF BEDROOMS: S BUILDER OR OWNER: ILd.b7�.- PERMIT DATE• COMPLIANCE DATE: DRAW DIAGRAM ON BACK N�o� n 1� o-zl! -c. 7� ,Ls c�- 2 ;i o` �,�