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0015 PINE VALLEY ROAD - Health
15 Pine Valley a 248-06�-002 -Hyannis s 0 'I Commonwealth of Massachusetts >,• � Title 5 Official , Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary-Assessments t- 15 Pine Valley.Road, Hyannis - ; M =248 P -67002 Property Address Mary Lipski c/o Mary Ryan Owner Owner's Name .., . information is required for every 137 East BayRoad Osterville MA 02655 f. ._3r, October,18, 2012 page. City/Town t a' ;`- t State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form.• , Important:When A. General Informationfilling out forms on the computer, use only the tab _ 1. Inspector: !,. . , {,. , C O•LI'key to move your cursor-do not _ i L Troy 1Nilllams use the return key. Name of In - Troy Williams Septic Inspections , Company Name � P Y a, 19 Hummel Drive' ' ,• .. - . • -. „ .. ... r Company Address r r . '' . . ' . SouthDennis-,^. MA City/Town State Zip Code (508)385-.1300 S1682 Telephone Number License Number B. Certification ;3 } w _ . I certify that I Have personally inspected the sewage disposal system afthis-address and thaf�t(ie f .information reported,below!is.true, accurate'and complete as of the-time of the insp ction. Th'eJnspe Rion was performed based on my training and experience in the proper function and mai tenance of on sR sewage disposal systems. I am a DEP approved system inspector pursuant to ction 15-40 ofi 1 ritle 5(310 CMR 15.000).The system:`` µ ; •-, : ; , ei, ® Passes ;; rcN► ,;:-• ,, ❑:Conditionally Passes _; ;,,❑, Fails.,. ❑.;Needs,Further,:Evaluation by,the Local Approving Authority 0ct6ber._18., 2012 Inspector's Signaituref, Date The system inspector shall submit a'coPY of'this insPection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is,a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the , report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t, ► � �51 I t5ins•11/10 Title 5 Official Ins tobsurface Sewage Disposal yst •Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Forms ' Subsurface Sewage Disposal System Form- Not for,,Voluntary•Assessments 15 Pine Valley Road, Hyannis M-248 P -67002 Property Address Mary Lipski c/o Mary Ryan ' t .1 : Owner Owner's Name . information is required for every-'1 y �37 East Ba Road Osterville MA 02655 'October 18 2012 . page. City/Town, +:t, 4, State Zip Code Date of Inspection B. Certification (cont.) , T ;•�� �'.i 1. 0 9 r _ 6;'r`1 �' is i�: ..t ',Pl "„ > t. ., T 'aT ,;�T,,d_' Inspection Summary: Check A,B;C,D of 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 meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. f - t B) System Conditionally Passes: 4i. r .- E 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. ~� r ^r .,uT"nj'a n u ' n o Check the'boic for yes", no or not determined",('Y, N, ND)for the following statements. If not determined," please explain. " The septic'tank is metal'androver 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`thafthe tank is less than 20 years old is available. e [ Y. w 0: N., :, - ❑ ND (Explain below): s r� ' 4 .' „• '�. �Y.ji Ic. ,"�. :.11' C�.' _..j-- - y •fit . ` ,r i°+� y%�^ �' } h"".9 Vc t5ins•11/10.•..... .' 4, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of IT. Commonwealth of Massachusetts +.. Title 5 Official- Inspection F.orm� Subsurface Sewage Disposal System Form . Not for.Voluntary Assessments' M 15 Pine Valley,Road, Hyannis M -248 P =67002 Property Address r Mary,Lipski c/o Mary Ryan Owner Owner's Name > information is 137 East Bay Road, Osterville t• MA .02655 . 1' required for every Y October 18,'2012 page. City/Town. State Zip Code Date of Inspection B. Certification (cont.) - B) ,System•Conditionally Passes (cont:): a7., 1. t f ., ❑ 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 ofBoard of Health): El "broken pipe(s)-are replaced ❑ Y El N r❑ ND (Explain below): ❑ " obstruction is removed ❑ Y ❑'N, —],,ND (Explain below): ❑ distribution box is leveled or`replaced, ,❑ Y ,❑ N ',,❑ ND (Explain below): N/A - , 1 + a.} ,�t•i�i ,t s ,a.i.I 'l.�a , t '...a,s . ❑ 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): N/A C);,Further Evaluationis Required by the Board of Health: �. :1.,• Y r ❑ 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. V Systein�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: ' `, ` t` . ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins♦11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System♦Page 3 of 17 6• Commonwealth of Massachusetts W Title 5 official.. lnspection .Form Fr: Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 15 Pine Valley Road, Hyannis M =248 P'-67002 Property Address Mary Lipski c/o Mary Ryan Owner Owner's Name information is 137-East Ba Road Osterville a• ' MA 02655 ' October 18 2012 required for every Y- • page. City/Town _ ttr 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 wa ter er 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 Weil*". 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'_ a c' .. r f jrx J a t N/A • D) System Failure Criteria Applicable to All Systems: You must indicate`,Yes"or."No'sto each of the followin for allins ections: 9 — P Yes No 41. y +� ❑ ,l .r ®- Backup of sewage intofacility or system component due to overloaded or clogged'SAS"or cesspool , ;, ,, 'jUscharge o`rapondingrof 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 ; , t5ins•11110 _ .. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts " Title 5 Official. {Inspection' Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- + r 15 Pine Valley Road, Hyannis M -248! P'-.67002 Property Address 1, <� Mary Lipski c/o Mary Ryan Owner Owner's Name information is required for every 137:East BayRoad, Osterville MA 02655,r October 18,,2012 . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) < t.. r a J! ti ._y Yes, No,,, , .-, El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ N, ..,, _ ;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 El, ® 4 ' 'tributary'to a surface water supply.' L f •:❑ ® f••,1 Any portion of a cesspool or7privy is within a Zone 1 of a public well. ❑ Any°porti-on of a cesspool or privy,is-within 50 feet of a private water supply well. C4 _ ❑ ® 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 :j f 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- 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 ;,r •f Y �f , i;system owner,should.contact the Board of Health to determine what will be ',necessary to correct the=failure:: - }... pie:i��4'r r`s7°` � �• 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:,!-1 Yes 'No ..- ,.. F 4 ❑ ❑ the system is within 400 feet of a's'urface drinking water�supply ❑ ❑ 1 the system is within 200 feet of a tributary to a surface'drinking water supply the system is located`in a nitrogen sensitive area (Interim Wellhead Protection '❑` ❑ Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Sectiori E the system is�considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large ' system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins,•,11/10 1 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 T t Commonwealth of Massachusetts Title 5 Official, Inspec-tion form =, , o Subsurface Sewage Disposal System form-'Not for Voluntary Assessments �a 15 Pine iValley Road, Hyannis _•, M -248 'P-67002 Property Address , Mary Lipski cto Mary Ryan `* Owner Owner's Name . information is . 137 East Bay Road, Osterville �`eF, required for every Y' MA 02655'� � . October 18, 2012<, 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 .. J .. , 7'. rL ;® ❑ 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? Z.. i- ❑`a f. ;Has the system received normal flows in the previous two week period? Have large volumes ' water been introduced to the system recently or as part of EJ ® ' ' this inspection? Were as built plans of the system obtained and examined? (If they were not °'' ® ❑ ` available note as N/A) ►, -,.;. ° ® . .,c0 1,Was,the facility,or dwelling inspected for signs of sewage back up? Z. '.^ ❑ 'ri Was the site inspected,for signs-of break out? FET '' t"•Were all'sy'stem 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 ihebaffles or tees, material of construction, dimensions de tti of liquid, de th of stud a and depth of scum? p s _q .p 9 P 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-- �A, ® ❑ 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 i Flow Conditions: i . ,, , r.lj is ;3 . _ ,. z rx,�..,� , r• 3 Number of bedrooms (design): _ Number of bedrooms (actual): :DESIGN flow based on 310 CMR-15.203,(forwexample: 1.10 gpd x#of,bedrooms): 330 gpd a„,F t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ; ' - �. ;�. • r . Title 5 officiaU In' spection. Form Subsurface Sewage Disposal System Form=Not for Voluntary•Assessments 15 Pine Valley Road, Hyannis f ' M -248 '-67002 Property Address t ,a Mary Lipski c/o Mary Ryan Owner Owner's Name requmation is every 137 East Bay,Road required for eve , Osterville MA 02655,'l October.18,'2012 page. City/Town State Zip Code Date of Inspection �.. D. System Information it Description: e Number of current residents: - 1 Does residencebave a garbage grinder?-- ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? 's .. . '. ® Yes ❑ No + ,,• Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d ,,a:., . , , 11=29,000 gals. g ( y g (gp �� 10=83,000 gals. Detail: 1 4 JZ �- Sump pump? El Yes ® No Last date of occupancy: ,, ,, occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A. flow Design based on 310 CMR 15.203 N/A { flow,(based Gallons per day(gpd) ,,,Basis of design flow(seats/persons/sq.ft.,.;etc):, y N/A Grease trap present? vt. - ❑ Yes ❑ No. Industrial waste holding tank present? J r t .. ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NIA t5ins•.11/10 M' Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 r t.a If' Commonwealth of Massachusetts •°�.s►,� +• Title 5 Official Inspection form Subsurface Sewage-Disposal System Forme- Not for Voluntary Assessments - 1 - w 15 Pine Valley Road, Hyannis ' 4.;. `' M -248. :P -67002 Property Address Mary Lipski c/o Mary Ryan Owner Owner's Name .. ' information is �-137 East Bay Road, Osterville MA M655: { ,•October 18, 2012 ., required for every y+ page. City/Town Y. :_ 1`` State Zip Code Date of Inspection D. System Information (cont.) ; '. _ ;. ; :•}.. . . �.. . - N/A Last date of occupancy/use: Date Other(describe below): General Information ' ,r Pumping.Records:,;,. .. Source of information: No pumping info was available. Was system pumped as part of the inspection? A" ❑ Yes ® No ' h _ If yes, volume pumped:!-,,.,' . gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool i. r Mkt_, - .„ . . v i ❑ Privy . ❑ ,..�,ti 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. • .` ,l. ElOther(describe): t5ins•11/10 a _,_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17 Commonwealth of Massachusetts . .► .. , i i,;r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments" ' =" 1.5 Pine,Valley Road, Hyannis M-248::� P'-67002 Property Address t Mary Lipski Go Mary Ryan Owner Owner's Name All information is 137 East Ba Road, Osterville MA 02655: ` required for every y� OCtOber 18,`2012 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: Tank, d-box and leaching pit#1 were installed in 1988rper compliance,,,New pit;#2 was added on 9/27/96 per compliance. Were sewage odors detected when arriving at the site? Yes ® No Building Sewer(locate on site plan):,- ,r Depth below grade: 24"+ feet r Material'ofconstruction: A:; ��• s ❑ cast iron ®40 PVC' ❑{other'(explain):` ... c- R .4 WA Distance from p r supply w rivate wateell or suction line: feet r F Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: -` .f 2.5'with.riser'to 6" feet ' Material of construction: r x • ..'f'r ® concrete ❑ metal ❑fiberglass •polyethylene.)�- - ❑other(explain) If tank is metal, list age: �- r,-x-" ,.•* years Is age confirmed by a Certificate of Compliance?.(attach a copy of certificate)-:'-,"El Yes ❑ No Dimensions: 1 . ; 5'X9'X6' 1000 gallon 41, Sludge depth: t5ins�11/10 r .y „ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 OfficialInspection-..Form w Subsurface Sewage Disposal System Form= Not for Voluntary Assessments< '' a 15 Rine Valley,Road, Hyannis 'M -248 - P -67002 Property Address Mary Lipski c/o Mary Ryan R Owner Owner's Name information is •137,East Bay Road Osterville til MA 02655. .. required for every Y October 18, 2012 page. City/Town ._ i.,: State Zip Code Date of Inspection D. System Information (cont.) • i Septic Tank(cont:) Distance from top of sludge to bottom of outlet tee or baffle; " ' "2 8 Scum thickness -: ,, 'IT, . .* r .,none Distance from top of scum to top of outlet tee or baffle u _ •"' 6" Distance from bottom of scum to bottom of outlet tee or baffle 1.4" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and concrete outlet tees were-found present and in working order. No evidence of leakage or damage was found. Tank was not in'need of pumping MINIS time. ' j Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: - ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A r Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•11110 q r. e r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts ° " A. 4 x �, Title 5 Official Inspection Form: 1 Subsurface Sewage Disposal System Form --Not for VoluntaryrAssessments- 1,' 15 Pine Valley Road, Hyannis 248 P'-67002 Property Address Mary Lipski c/o Mary Ryan Owner Owner's Name information is required for every 137�East.Bay Road, Osterville MA 02655.., - :",October 18,.'2012. page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,"evidence of leakage, etc):' N/A V. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A rf Dimensions: N/A _ . ` Capacity:t N/A a • gallons - N/A Design F.low:`Ma -;,;•f.,_ 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.).- N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts =: -F::,Xcll 1 r Title 5 Official, lrispection Form Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments 15 Pine Valley Road, Hyannis - .M -,248 P 67002 Property Address Mary Lipski c/o Mary Ryan rc ,• Owner Owner's Name information is required for every y 137 East Bay Road, Osterville ,.` MA 02655: r t October 18, 2012• ,s page. City/Town ,. a_ -,:, State Zip Code Date of Inspection D. System Information (coat.) ; �• -` _ . . ,e •' �.. - , Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level i Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. . r e Pump Chamber(locate on site plan): :r Pumps in working order: ❑ Yes ❑ No Alarms in working order: i, ❑ Yes . ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required):' If SAS not located, explain why: 1 t5ins•11110 z Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 12 of 17 1 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal,System Form-=-Not.for Voluntary Assessments 15 Pine Valley Road, Hyannis •r,. . : - 'M _248 -P -67002 - Property Address ; Mary Lipski c/o Mary Ryan Owner Owner's Name information is every ;137 East-Bay-Road, re uired for eveOsterville =�, MA 02655..; a October 18, 2012 . page. City/Town r,*•1 State Zip Code Date of Inspection D. System Information (cont.) s'. *- Y ® leaching pits number: ` 2 -4'X6' pit with 2 of stone ❑ leaching chambers number: ❑ leaching galleries' number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions:' El overflow cesspool number:,6. ,f , ' s ❑ 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.): i Leach pit#2 was found with water level approx. 24"below inlet. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Leach pit#1 failed in.1996 when new pit was installed. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A ' r Depth ' top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A ; Materials of construction N/A N Indication of groundwater inflow El Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 O ficial Inspection FormF Subsurface Sewage Disposal System Form =Not for Voluntary Assessments IL:,• 'a' F _ 15 Pine Valley Road, Hyannis r -M-248 P L 67002 Property Address Mary Lipski c/o Mary Ryan Owner Owner's Name information is '137 East Bay Road required for every Y OSterVllle l' MA 02655 c.' +October 18, 2012 . . page. City/Town ,n 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.): N/A Privy(locate on,site plan): Materials of construction: N/A Dimensions r.t N/A Depth of solids Comments (note condition of soil;signs of hydraulic failure; level of ponding, condition of vegetation, etc.): e . N/A f` — `�f.. . er , 1.. 1 ,. �rL ..r.{ .�r .. arm 3' . • r • t5ins•11110 ,. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i vv �Y i �f Commonwealth of Massachusetts Title 5 Offica Inspection Form Subsurface,Sewage Disposal System Form - Not for Voluntary Assessments I w r 5 Pine Valley Rfoad, Hyannis M-248 P -67002 y !Property Address Mary l i0ski c/o Mary. Ryan Owner Owner's Name infogmation is i A-, required for every` 1371 East Bay Road;,Osterville MA 02655 October 18, 2012 a page. i Ctty/T van ,� I State Zip Code Date of Inspection' 1 k, '{ D Y Y yst6m Information (cont.) d: Sketch Of;SeWago 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 waterlsupply enters the building. Check one of the boxes below: 4 , ; 'j' a ,handVsketch in the area below •i t ji'� drawing attached separatgly g d v i 1 ! 1 1 i 1 111 - 0 01 k 4 1 + Zt 7 If .• 1 '� �i � i` r � 'i a .1 bins•1�',f10 I bt,i '; ° Tltfe 5 Officlaf inspection form:Subsurface Sewage Disposal System•Page 15 of 17 ?$0 Commonwealth of Massachusetts W Title 5 Official orm�Inspection p Subsurface Sewage Disposal System Form- Not for VofiU'ntary Assessments '+ i ; ,, ` { 15 Pine Valle Road, Hyannis t M-'248 sP.,-67902 Property Address Mary Li ski c/o Mary Ran Owner Owner's Name information is s required for every 137 East Bay Road, Osterville MA 02655 ! 4 October 143; 2012, R� page. Cityrrown State ',411 Zip.Codf, Dale of Ins0egtlon+' D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water c Y ® Check cellar j ' P i '•'; o d ❑ Shallow wells Estimated depth to high ground water: d e�t�+j Please indicate all methods used to determine the high ground water elevati ® Obtained from system design plans on record If checked, date of design plan reviewed: 4 0 3/30/88 11$ ' ► I Date 1 I i � � ' BI ' ;� ��f �• ' Q ® Observed site (abutting property/observation hole within 150 feet�of SAS) i ❑ . Checked with local Board of Health -i explain: � ) a !I, ElChecked with local excavators, installers- (attacih docua me�ntation)i�i, t. ® Accessed USGS database-explain: I MIW 29 Zone D 9.5' 6.3' adjustment "l ° You must describe how you established the high ground water elevhatiori' �{ A Test hole recorded on plan showed no water found at 12.0'. Hand gauge je ,#, belov bottom of leaching with no water found at a depth of 13.0'. USGS Groundwater map�sh 'wes g5roun' water atl : minimum of 25.0'. Groundwater adjustment at the time of inspection was 6. "+ Bottom 1of Teaching at. 9.0 was found not to be located in the high groundwater elevation at the time f Ins ecti'on. i. 1 . ._. �1' i yy , Before filing this Inspection Report, please see Report Completeness Checklisf on next pave. f (( t5ins-11/10 Titie 5 Official Inspectit Form:Subsurface Sewage Disposal System-Pagt H of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Pine Valley Road, Hyannis M -248 P -67002 Property Address Mary Lipski c/o Mary Ryan Owner Owner's Name information is required for every 137 East BayRoad Osterville MA 02655 October 18 2012 page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pp[ication for ;Digpolal bpgtem Conotruction permit Application is hereby made for a Permit to Construct( )or Repair( �n On-site Sewage Disposal System at: Location Address or Lot No. / S -�. (� � Owner's p l�Name,Address, and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (W o-w,.�Osi -C, . ;ta 6 Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��_ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil uy,-&n Nature of Repairs or Mterations(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 vironmental Cod and n lace the system in operation until a Certifi- cate of Compliance has bee az ig�`ned Date Application Approved by e5!5�7 Dates' Application Disapproved for the fol owing reasons Permit No. 90-**''' V F,? Date Issued 9 .� aZ `�g 00 Dom.. . • ��p G?� No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZppYication for ;h9po5al bpgtem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at: Location Address or Lot No. , S (t U��(. Owner's Name,Address annd/Tel.No. Assessor'sMap/Parcel r' ` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �n 0-c wcxe_sip, C) 6 Y, : t Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '� � gallons per day. Calculated daily flow '7413n gallons. Plan Date Number of sheets Revision Date Title Description of Soil �&LrNc� 5 A V p Nature of Repairs or Alterations(Answer when applicable) -7-JAZI 'w�a ✓J Cx '1%— r l F 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 gvironmental Code and not-to—lace the system in operation until a Certifi- cate of Compliance has been issue&Tthi '.©ard f eal t Signed Date Application Approved by Date Application Disapproved for the foll wing reasons Permit No._7 �,�_ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on by _ Installer v t. ram Ns i at ti V I has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Date Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No.------------------------------------Fee----- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �Digotar *p!6tem Construction Permit Permission is hereby granted to construct( )repair( On-site Sewage System located at No.# ,c.-�.__t ✓l r� r Sum and as described in the above Application for Disposal System Construction Permit. v No.' Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: tl,-- Approved by Board of Health t f � mod' yo.t 16 ; sz•s �I 53.1 //4.99 1-6 1�G tip 2 t 4,tonz _ rPi_ 3q2 ,pd . o-t 17 41 R v e.7 /acne I _ i 11, 7^0 j 5? �. 24 29rp� 4 90ad i I 4�4 'I J_ o' W "-'-' CFO /WiA.c I rOt 18 i� C m /�0 r d9,t` j O J a /00 0 I , 52.E 62.1 !s 4917tt Cape £"eeAin 50.0 3 c19 /da tbot load ;C f 1.1 yamaA, &. 02601 —Pot 19 Ol Data Alo. bed ioonvi 2 Scc�e 1 "-30 r ),I)o� no J6 rc 9-7-88 fat. Low 220 `p. No Sca& atea 20LI i j ke4,vwe " 20LI a$ I Capacity 392 9.p, 1000 Ll 'Pit I.l, t q stone I 4 z.o L' 2 Sketch Pt an o f .('and in 144ami4, 11 ia. 90a xo,✓ca-iaae muApl'uq >e tot 17 aa, elwwn on a pta a od 110ak C"-d t" rezo&ded i a bk 145 pc,. (37. �to a t;o" c,.,e ba4.ed on cut as s. twted dattmt. 7,o a7P O- i WZ7-T .. �Je4.t I-'i.ts'tr)-706 3 �-iaja -30-88 i No !ea ten E.zcowt to to j'ea c. 2 rr..i,ra p et I " --- 49 f 48.3 4 3 titonP�. �•� rZe�. 4 5.9 4G•3 I r,;.E-tl�urrti rtiec%acr- 44� Of H. I ..lul �cwu1 ttNE No.3?-490 �ECIsi ER p� Commonwealth of Massachusetts p0T Executive of.Environmental Affairs DEPQZ Department of �. Environmental Protectionei i jJ,3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART A CERTIFICATION ASSESSORS N 0: PAROII NO: Property Address: �S N� v� �g� y,�.»� 5 N1 P, , Address of Owner: (if different) D ate of I nspection: 4,k 91�3 ``r�- Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel: (508)4771420 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system ---- Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority �( Fails Inspector 's S ignatur �&JDate: , The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: NS Q1, Owners : Date of Inspection . �`t3�5 INSPECTION SUMMARY: Check A,B,C,or D A) SYSTEM PASSES: ---- I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM R 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: •--- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If"not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration ,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. --- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). -••-- broken pipe(s) are replaced ----_ obstruction is removed ---- distribution box is levelled or replaced --- The system required pumping more than four.times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ----- broken pipe(s)are replaced ----- obstruction is removed C ? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : �S P►tip u� �S+ Owner : Date of Inspection: C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: -- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health, safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HE ALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply wen,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: kI have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identwied below. The Board of Health should be contacted to determine what win be necessary to cor- rect the failure. X Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: N5 Owner: ty,,LP�ny Date of Inspection : D) SYSTEM FAILS (continued) 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 over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply PP y ortributary 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 water supply well with no acceptable water quality ana- lysis. It the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i5 P�N 0 wner. Date of Inspection: a Vza cib E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : -- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area -IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: \S Owner: H\jt_,�'_� Date of Inspection: Check if the following have been done : -x Pumping information was requested of the owner ,occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components,excluding the Soil Absorption System, have been located on the site. ---x The septic tank-manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions,depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Sod Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods --x The facility owners and occupants I different from owner were provided with information on the proper maintenance of Subsurface Disposal System. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: lkksi k\, Date of Inspection: q�r ak'1P RESIDENTIAL: Design flow: 630 gallons Number of bedrooms : 03 Number of current residents: 8'!,, Garbage grinder (yes or no) : NNc� Laundry connected to system (yes or no):Ar— Seasonal use (yes or no) : vzba Water meter readings,if available: cam` Last date of occupancy : $Zi� COMMERCIALANDUSTRIAL : Type of establishment: Design flow: gallons/day Grease trap present: (yes or no) Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no) : Water meter readings, if available: Last date of occupancy : Other: (Describe) ..................................................................................................:......... Last date of occupancy: GENERAL INFORMATION FjJMPING RECORDS and source of information: 7, System pumped as part of inspection (yes or no):...... C'--)..... if yes,volume pomped: .................... gallons Reasonfor pumping :............................................................................................................ i� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of inspection: 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) --- Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known)and source of information ....f.kgt ...... .. Z..��.5.......................................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).... SEPTIC TANK : .. ..... (locate on site plan Depth below grade: ..!��.. Material of construction: ...k concrete ......... metal........ FRP........ other (explain) Sludge depth :..6.......... , Distance from top of sludge to bottom of outlet tee or baffle:......sy.................. Scum thickness:..................... Distance from top of scum to top of outlet tee or baffle: ...........1-0....................... Distance from bottom of scum to bottom of outlet tee or baffle:....1•.a`................ Comments : (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc. . .... .. ..5. r.....��.... .. �Y1 S.l`?5.. ..t.0 1. . .. . .c.,;�r.�...�1� � O V.14�►..: : .Ql?�:.... ... 1�?v .�"..�.��Z�g-U���i ?�' �.,.... .... �. �.............. �4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: VS \ImLL, Owner: �u2Qhv� Date of inspection: fhb GREASE TRAP: ..... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:...�1C�.. (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................................ Dimensions:..... imensions:..... Capacity:....................gallons Design flow:.... low:..... ...... ....gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................. ................................................................................................................................................ I a r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Owner: iy—\, Date of inspection: -5'�va\C�b DISTRIBUTION BOX:... 5 (locate on site plan) Depth of liquid level above outlet invert%.&Aw?4 C-sv�—N— Comment: (note if level and distribution equal evidence of solids carryover, evidence of lea age into or out of box,etc.).. -`4 �x.�:ca. u-±, .. .. xs�u mR PUMP CHAMBER:....IZ� (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):..... . .... (locate on site plan, if possible; excavati required, but may be approximated by non- intrusive methods) if not determined to be present, explain: . ................................................................................................................................................ .......................................� � �� ..�1 .... . ... .................................................................. Type: leaching pits,number: ...`.. ... leaching chambers,number:........ leaching galleries,number:........... leaching trenches,number ,length:..................... leaching fields,number, dimensions:................... overflow cesspool,number:.......... Comments: (note n of soil, s rrs hydraulic failure.level of pgnding, co%ition ofwegetation, etc.). !gcdKK* ��, ,. �Y\ �. r � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 1S Pt tie_ Owner: �kvtQ* Date of inspection: CESSPOOLS:....&. ;?. (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PRIVY: ...},QC).. (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: NS PO kA- Owner: ►�1v�e� Date of inspection: �`�zAti SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' A3'3�- D � O DEPTH TO GROUNDWATER: Depth to groundwater: �:2*.feet Method of determination or approximative: US.. al �ca� �a. . ........................................................................................... ................................................................................................................................................ ................................................................................................................................................