HomeMy WebLinkAbout0146 ROSARY LANE - Health 146 Rosary Lanel► .
Hyannis
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of
COMMONWEALTH OF MASSACHUSETTS V5-
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a r
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
��' S•�� David B.Mason,R.S,Certified Title V Inspector,508-833-2177
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 146 Rosary Lane,Hyannis,MA
Owner's Name:Johnson
Owner's Address: , 120 Seabrook Village,Mashpee,MA
Date of Inspection: May 9,2008
4
Name of Inspector: (please print)David B.Mason t ,•
I
Company Name: F
N.A. `z
Mailing Address: 4 Glacier Path
East Sandwich,MA 02537R
Telephone Number: 508-833-2177 ---
4:6 Cis
CERTIFICATION STATEMENT ' _
I certify that I have personally inspected the sewage disposal system at this address and that the info rmation,reported;
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP <<
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syst
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signatu;;;�� 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.
Notes and Comments: Tank should be pumped as a matter of maintenance. The information as identified represents
only the condition of the system on May 9,2008 at Noon.
****Thus 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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I 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: Parking area should be defined to prevent parking on septic tank and pump chamber.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Page 3 of 11
PART A
CERTIFICATION(continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public 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 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:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
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Page 4 of 11
CERTIFICATION (continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_NA_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
NA_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
NO_(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.
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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
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Page 5 of 11
Property Address: 146 Rosary Lane, Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X _ Pumping information was provided by the owner,occupant,or Board of Health
_X Were any of the system components pumped out in the previous two weeks?
_X _ Has the system received normal flows in the previous two week period?
_X Have large volumes of water been introduced to the system recently or as part of this inspection?
_X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X _ Was the facility or dwelling inspected for signs.of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X _ Were all system components,excluding the SAS, located on site?(INCLUDING THE SAS)
_X_ _ 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 ?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
e and location of the Soil Absorption System SAS on the site has been determined
The size p y (SAS) based on:
Yes no
_X _ Existing information.For example,a plan at the Board of Health.
_X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 146 Rosary Lane,Hyannis,MA
Owner: Johnson
Date of Inspection: May 9,2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_ Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): (Not Allowed)
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy.
COMMERCIAL/INDUSTRIAL
Type of establishment:_Food Service
Design flow(based on 310 CMR 15.203): 330 gpd
Basis of design flow(seats/persons/sgft,etc.): Take out-No seating_
Grease trap present(yes or no):NO_
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO_
Water meter readings,if available:
Last date of occupancy/use: Within 1 year
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Barnstable Board of Health
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:Maintenance pumping conducted after inspection
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_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): With pump chamber
Approximate age of all components,date installed(if known)and source of information: Installed 9/27/05
Were sewage odors detected when arriving at the site(yes or no):NO
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
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Page 7 of 1 I
SYSTEM INFORMATION (continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
BUILDING SEWER(locate on site plan)
Depth below grade: Approx. 12 Inches
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition.
SEPTIC TANK: N.A.(locate on site plan)
Depth below grade: 10 Inches
Material of construction:_X_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: Typical 1500 gal.
Sludge depth:4 inches
Distance from top of sludge to bottom of outlet tee or baffle: 28inches
Scum thickness: variable 0 inches to 6 inches
Distance from top of scum to top of outlet tee or baffle: 0 inches
Distance from bottom of scum to bottom of outlet tee or baffle:Not applicable no scum at outlet tee
How were dimensions determined:actual measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.)inlet tee is PVC.Outlet tee is PVC and appears in good
condition. No evidence of leakage. Structure of tank appears adequate.Effluent level with outlet tee. Maintenance
pumping is required.Tank is H2O.
GREASE TRAP: N.A.
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
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Page 8 of 11
SYSTEM INFORMATION(continued)
Property Address: 146 Rosary Lane, Hyannis,MA
Owner: Johnson
Date of Inspection: May 9,2008
TIGHT or HOLDING TANK: N.A._(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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: YES_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Level with 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.): There is no indication of solids carryover,dbox is in good condition. Dbox is 12
inches below grade to risers. 2 outlets which are level.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
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Page 9 of 11
SYSTEM INFORMATION(continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number:_2_5'x8'precast with 4' stone around
_leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions_
overflow cesspool,number:
innovative/alternative system Type/name of technology.
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): leaching is 32 inches below grade. Riser is not present.Chambers are an H2O rate pit. No indication of
ponding nor increase growth of vegetation. Probing did not indicate damp soil.
CESSPOOLS:_NA (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 or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_N.A._(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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
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Page 10 of 11
SYSTEM INFORMATION (continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
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.
2
A O
Front
W
Septic Tank Al 26'
B 1 47'
D-Box A2 38'
B2 55'
Leaching A3 44'
B3 60'
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
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Page 11 of 11'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 146 Rosary Lane,Hyannis,MA
Owner:Johnson
Date of Inspection: May 9,2008
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_20_feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH
_X_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting
site topography does not indicate ground water to be within 4 feet of bottom of leaching facility. Test holes in the
area on file do not indicate ground water within 20 feet of grade.
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Barnstable Assessing Search Results Page 1 of 2
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Owner: 2008 Assessed
Values:
JOHNSON DAMON,JOANNE
146 ROSARY LANE Appraised Value Assessed Value
Map/Parcel/Parcel Extension Building Value: $67,200 $67,200
345 /017/ Extra Features: $0 $0
Outbuildings: $ 1,900 $ 1,900
Mailing Address Land Value: $ 128,500 $ 128,500
JOHNSON DAMON,JOANNE
Totals $ 197,600 $ 197,600
120 SEABROOK VILLAGE
MASHPEE, MA.02648
2008 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation)
Community Preservation Act Tax $35.77 Fire District Rates Town
Barnstable FD-All Classes $2.04 $6.58
C.O.M.M. -All Classes $1.03 Commei
Hyannis FD Tax(Commercial) $325.05 Cotuit FD-All Classes $1.33 $5.80
Hyannis FD Tax(Residential) $90.70 Hyannis-Residential $1.53 Persona
Town Tax(Commercial) $802.26 Hyannis-Commercial $2.35 $5.80
Town Tax(Residential) $390.06 Hyannis-Personal $2.35 Other R:
W Barnstable-Residential $1.86 Commur
W Barnstable-Commercial $1.86
W Barnstable-Personal $1.86 i
Total: $1,643.84
Construction Details
Building PropertP en tLy9Skdetch & ASBUILT
Building value $67,200 Interior Floors Vinyl/Asphalt
Style Stores/Apt Interior Walls Plastered
Model Commercial Heat Fuel Gas
Grade Average Heat Type Hot Water
Stories 1.5 AC Type Central
http://www.town.bamstable.ma.us/assessing/assess/displayparcelO8map.asp?mappar=3450... 5/12/2008
0Barnstable Assessing Search Results Page 2 of 2
Exterior Walls Asbest Shingle Bedrooms 02
Roof Structure Gable/Hip Bathrooms 1 Full
Roof Cover Asph/F GIs/Cmp living area 832
Replacement Cost $87274 Year Built 1926 _
Depreciation 23 Total Rooms "
LandI Wag
CODE 0326 ,( - .
Lot Size(Acres) 0.11
Appraised Value $ 128,500
AsBuilt Card N/A
Assessed Value $ 128,500
View Interactive Map
-
Sales History:
Y
Owner: Sale Date Book/Page: Sale Price:
JOHNSON DAMON, JOANNE Oct 3 2005 12:OOAM 20327/261 $240,000
CROTEAU, MICHAEL&JAYNE Mar 17 2003 12:OOAM 16584/100 $ 122,500
CLARK, MELVIRA EDITH Mar 17 2003 12:OOAM 16584 $0
CLARK, MELVIRA E& ROBERT S $0
Extra Building Features
Code Description Units/SO ft Appraised Value Assessed Value
PAV1 PAVING-ASPHALT 520 $ 1,900 $ 1,900
Property Sketch
Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area UST Utility Area(Unfinished)
(Finished)
FAT Attic Area(Finished) GAR Garage UTQ
Three Quarters Story
(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story
(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/assessing/assess/displayparcel08map.asp?mappar=3450... 5/12/2008
Town of Barnstable
OF THE 1p� .
o Regulatory Services
BMWSTABLE, Thomas F. Geiler, Director
9`� 1639. ��� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector,who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
�f TOWN OF BARNSTABLE
`LOCATION ` l/V 054k y SEWAGE# /•%om"—T
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I?dER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY SrooC s' C' �-
LEACHING FACILITY:(type) ^ /_(size)
NO.OF BEDROOMS C
BUILDER OR OWNER �/ c
PER444-T DATE: "d 7 e/ ®-f-- COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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LEACHING FACILITY: (type VA i.4./eIZ5 (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: _COMPLIANCE DATE: 3 0 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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