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0356 SCUDDER AVENUE - Health
356 Scudder Avenue , a Hyannis A = 288 045 8 y F N z TOWN OF BARNSTABLE LOCATION ale SEWAGE# j VILLAGE ASSESSOR'S MAP&PARCEL IN NAM &PHONE NO. SEPTIC TANK CAPACITY �Q 6(!:5 C-" LEACHING FACILITY:(type) (size) k � NO.OF BEDROOMS �� � OWNERc���c,�` PERMIT DATE: COMPLIANCE DATE: 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 FURNISHED BY L Ju eL Cv � c a a 1= w 711� Qj L i r� TOWN OF V STABLE LOCATION 2C6 WAGE # VII,-"A`GE ASSESSOR'S MAP & LOT2 R46TAM ;S NAME&PHONE NO. SEPTIC TANK CAPACITY /coo 1 LEACHING FACILITY: (type) �X / s (size) NO.OF BEDROOMS 2 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ � a � 'ZS c� n �� � -�6 �S � �. �� u ��� -� �, .�. ., ,. . f .r ,, C-1-10 1 ( � 3 �� McKenzie, Marybeth From: Tara Pottebaum <pottebaum.tara@gmail.com>. Sent: Thursday,July 16, 2020 9:49 AM To: McKenzie, Marybeth; Doug Rooney Subject: 356 Scudder Ave and Chickens and Black Lives Matters sign Hi Marybeth, Including my husband Doug. My husband and I spoke yesterday after your visit to the house. And we struggled to identify the date or time when the chickens were not on our property. And if the chickens weren't on our property, we are surprised our good neighbors wouldn't have left us a note or knocked on the door? We'd round them up, figure out how they got out and work to make sure it didn't happen again! Versus escalating things and creating animosity between neighbors by filing a nuisance complaint with the town? And since you stated it was in the past few days, it occurred to us that a few days ago is when we put the Black Lives Matters sign on the yard. Going forward, please make sure you have specific date, time, and pictures of the chickens being a nuisance! You also mentioned that there was a state regulation to record chickens in a Barn Book. And that if I emailed you, you would provide me with the information about the Barn Book. Best Regards, Tara and Doug 1 s • BIACNIRIES Lp IS LUV III WIN E x r s + a w• I A,1 p Commonwealth of Massachusetts Title 5 Official Inspection Form 04P _ Subsurface Sewag )le e Disposal System Form Not for Voluntary Assessments ;.. 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis . MA 02601 June 4, 2015 page. Cityrrown 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 filling out forms A. General Information on the computer,use only the tab 1. Inspector: I --a1 0 q 1 �33 key to move your cursor-do not Patrick T. Sullivan use the return key. Name of Inspector ---- Ready Rooter Excavating vt:,�A Company Name P.O. Box 89 Company Address Forestdale _ MA 02644 City/Town State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and fh''at the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �---- June 10, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system 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. r t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is Hyannis MA 02601 June 4, 2015 required for every _ Y _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 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. l 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 o d* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or xfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced ith a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspec i n if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank * less than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. •° 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis MA 02601 June 4, 2015 —y _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or brea out or high static water level in the distribution box due to broken or obstructed pipe(s) or die o a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replac d ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remove ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is I eled 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 /i.❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required y the Board of Health: ❑ Conditions exist which require f rther evaluation by the Board of Health in order to determine if the system is failing to protect ublic 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 sys�m is not functioning in a manner which will protect public health, safety and the environ�tnent: ❑ Cesspool or prey 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ! 1 Commonwealth of Massachusetts _ Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every �H annis MA 02601 June 4, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soi absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tribu ary to a surface water supply. ❑ The system has a septic taXSAAJS� S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic taS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank ad the SAS is less than 100 feet but 50 feet or more from a private water supp Method used to determine di ance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is Hyannis MA 02601 June 4, 2015 required for every y _ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 rf of a surface drinking water supply ❑ ❑ the system is within 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is loc ted in a nitrogen sensitive area (Interim Wellhead Protection Are/3CMR a mapped Zone II of a public water supply well If you have answered "yestion in Section E the system is considered a significant threat, or answered "yes" in Secthe large system has failed. The owner or operator of any large system considered a sign under Section E or failed under Section D shall upgrade the system in accordance wit5.304. The system owner should contact the appropriate regional office of the Dep t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is June 4, 2015 Hyannis MA 02601 required for every Y page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the 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, i d menslons, 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD _ 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 4 Commonwealth of Massachusetts f Title 5 Official Inspection Form 14 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis MA 02601 June 4, 2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes 10 No Water meter readings, if available last 2 ears usage d 2013= 63 GPD g ( y g (gp )) 2014= 58 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., tc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank prese ? ❑ Yes ❑ No Non-sanitary waste discharged the Title 5 system? ❑ Yes ❑ No Water meter readings, if avai able: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonweal. � th of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto _ Owner Owner's Name information is required for every Hyannis MA 02_601 _ June 4, 2015 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter records: Pumped 05/16/2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is Hyannis MA 02601 June 4, 2015 required for every y _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 07/14/1992. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1.5 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: 8.6'X 4.5'X 4.5' 1000 gallons Sludge depth: 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis MA 02601 June 4, 2015 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1.5" at inlet .5" at outlet Distance from top of scum to top of outlet tee or baffle 101, Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. 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 PVC tee and concrete outlet baffle in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Tank in good condition. Pumping not needed at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet l Material of construction: ` ❑ concrete ❑ metal M fiberglass ❑ polyethylene ❑ other(explain): ,I Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is H required for every annis MA 02601 June 4, 2015 y _ 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑/erglass ❑ polyethylene ❑ other(explain): Dimensions: -- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Fage 11 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 356 Scudder Ave. _ Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis MA 02601 June 4, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. Very light solids carryover. No high water staining over outlet invert. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, ondition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .,, 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis____ MA 02601 June 4, 2015 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'X 4'w/ stone. ❑ leaching chambers number: ❑ 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.): Camera used to inspect leach pit. Liquid level 3.5' below invert at time of inspection. High water staining 1.5' below invert. No sign of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . _ 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis MA 02601 June 4, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - / -- i i i Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, sign of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner Owners Name information is required for every Hyannis MA 02601 June 4, 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately rasa J�, i t C_e " j A i- aa, R t t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts 4 t4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 356 Scudder Ave. Property Address Robert Bearisto Owner. Owner's Name — information is required for every Hyannis MA 02601 June 4, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope p ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: '2 - 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous Title 5 report 2005. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: maps.massgis.statarna.us/oliveU p You must describe how you established the high ground water elevation: Certified Soil Inspector detemined adj high ground water below base of leach pit in 2005. Accessed local ground water contours and topo mapping Base of leach pit is above high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 356 Scudder Ave. Property Address Robert Bearisto Owner Owner's Name information is required for every Hyannis _ MA 02601 June 4, 2015 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT_gli.p INSTALLER'S NAME S& PHONE NO. SEPTIC LANK CAPACITY LEACHING FACILIT.Y�tVpe) j - (size) pQ7. NO. OF BEDROOMS__PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:_ �- VARIANCE GRANTED: Yes No i IPA O p 15 I • TOWN OF BARNSTABLE 1 'LOCATION 3S ( �SE',t�eQGCee A:e SEWAGE �I , VILLAGE � y� T 4Qrl ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 4000 4�/ LEACHING FACILITY:(type) ,% (size) 610.0 ' NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER (J DATE PERMIT ISSUED: 3 DATE COMPLIANCE ISSUED: �- VARIANCE GRANTED: Yes No L _ .�� .�. r .� � � � � � � � � Y" � c��`� r'` . nl � _ - �� .ram _ _ _N � � .�. . � , , , ASSESSORS MAP N0: T PARCEL N0: 30.00 ........................... THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOAR® OF HEALTH ALBarnstable Conservation Department TOWN OF BA R N STA B LE N'6-11—�- .*,e- � sien� ppitr�t Dim al�g1 lark To t �r r inn rruti# Application•is hereby made,for,a-Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 356..Scudder Ave Hyannis ---------------------.....-....................................................................... -•---.._..---------•-----......--•--••---....•-----------•------------•--•-------................. Location-Address or Lot No. .EaP.D. =S...------•---...-----•----•----------------------•--...--••-....----•-----•---- ............................................. ............................................... W J.P.Ma e o mb e r Jr. Owner Address Installer Address Type of Building Size Lot............................Sq..feet DwellingX No. of Bedrooms-------------r.3..........................Expansion Attic ( ) Garbage Grinder ( Other—T e of Building .......... No. of persons............................ Showers Q, � ------------------ P ( )--- Cafeteria l ) Other fixtures --------------------------------------------------------- •-••.... .......... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................... .............................................. Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....................... �14 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a ..........-..................................-............................................................................................................... 0 Description of Soil......................................................................................................................................................................... xSand & Gravel -----------•---------------------------•---•---------_...-- V d --- G W --------------------------------------------------------------------------------------•-----------------------------------------------------------------------------------......--------------•-•-•---- M. Nature of Repairs or Alterations—Answer when applicable.__............................................................................................. ....1-1000...Eallon---p?it 1_-leacging..i??t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian e has b n •ssued by the oard ealth. Signed .... G% � /3 /92 Date ApplicationApproved By ----------V -- ----- �e ------------------------------------------------------------------------ Application Disapproved for the following reasons• .................................................................................................................................... ....................................................................q---------------------------.....-......----...........----...---------------------------------- ------------------ ........--------- ---------------- Permit No. ....... -a`--- a'/.�........................ Issued ...-- -- ------ .-- --.........---....----.Date----.. Date No.jg 30.JO _ f Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` TOWN OF BARNSTABLE Appliration for Uinpnout lVurkii Tong#rnriiun runtit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 356 Scudder Ave Hyannis ................_................................................................................ --•-••--••--...........--•--•-------•---•-•---......-----•--...-------•-•••------...........••---- - Location-Address or Lot No. -......................................... •----......----•-------... ..........--...................................................................................... W J.P.Ma e omb e r Jr. Owner Address Installer Address ,t dType of Building Size Lot............................Sq. feet- U Dwelling X No. of Bedrooms............. 3..........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of,Buildiu " No. of persons............................ Showers — Cafeteria N YP g</ P ( ) ( ) Otherfixtures -------------------------------------------------------------------------•-•-•-......• ••••-•---•-•----•••-••••-••--••-•.......-----•---••---•--•--- W Design Flow.............................................gallons p`er person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY............................................................'............. Date................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' ----------------------------------------------------------------------------------------------------......................................................... ODescription of Soil....................................................................................................................................................................... W Sand & Gravel V -•--•-•-•--•-•-------------•-------••-•-•....._...........-•---•••-•-•-••----------•-••••••••------•••-••••-----•------•----------•••-•-•-•------------•••••••-•-••-•••••-••......•---•-----••-•----.... UW ••••-•---------------------•-----.....--•-•-•.....•••-•-••----......••--•••------------•--•---•----•----•-••--••---------------------------•......•..................................................... Nature of Repairs or Alterations—Answer when applicable-- 1-1J9!)...g.&llon_-pit- 1•-leacin ...pit. ---------------------......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be nniissued by the boardoPoPhealth. Signed - .��'� ��{`.............. ._ 3. 92 .. - , 6 ----------------------------- Dare Application Approved BY .... ...t <. . ... ' -------_ --------- Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------- ------------------------------ -- ----- ------------------------------------ ------------------ ----- --- ---- ---------------------------- ---------------------- -------------------- ........................................ Date PermitNo. ........ ."?----= "f ------------------------ Issued ...............--- --...-- --.....---- ------------------...... Date THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE Trr#ifiratr of C�araylianre T S S TO T Y at the Individual Sewage Disposal System constructed ( ) or Repaired ( XX ) Niac9Ae� T by-------------- . -- ...............-----...................---..............-------------------------------------------........................................................... Installer at056....Scudder----Ave--H-yanni-s---------------------------------------------------------------- ------------------ - --------------- ----------------------- ------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....; �-------a---1?--a....------ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ....................................-------------�----`-.. V -----------------................... Inspector -------------------- -------- ------------------------------------ ------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE..$... 30.00-- Disposal Worb T.nnstrnrtioln anti# Permission is hereby granted.....A_.P..Maeomber Jr.............................................................................................. to Construct ) or Repair �X) an Individual Sewage Disposal System at No..35((Jjcudder_._Ave.... Iyannis..., Street as shown on the application for Disposal Works Construction Permit No. kh.. Dated.......................................... -------------------------•-•--.�'-r�-- ------------------------------------------------- Board of Health DATE...............................:;;.f-.......-.--•--�:.i............................. FORM 36 508 HOBBS&WARREN.INC..PUBLISHERS r COMMONWEALTH OF MASSACIIUSETTS CUTIVE OFFICE OF&iMONMENTAL AFFAIRS DSPARTVZNT OF ZNMONYBNTA 1 PROTZMION i ,}n • d�yj Ya . OFFICIAL INSPECTION FORM-NOT�� 5 SUBSURFACE SEWAGE DISPOSAL ASSESSMENTS FORM PART A CERTIFICATION Property Address: 3S( � ,, �P Owner's Name... f Owner' 6 7 r s Address; Date of Imo. or i:� ► T p�G�� - 06�� 0 ump fihmputor.(PIe�Print) Ma7ingAddnas. s} c -r• D d, Telephone Number._A _ �0�6 c�.t 1 r _..a rn CERTIFICATION STATEMENT I aerdiy that I have ply VecW� below is tree,accufe and oft as of thetfteeo� sY�m at this address��at WowaW �8 and exparieaoe in the proper of the inspection, won was pedo an d aPP�'ed system inspeoumy �r p to mamtm °0e I=site seisedivwalovems.I am a D", 13�40 of Me S(310 Elft 13.000), Tbe gym: pass" P-M- oily ptissm Needs Fudher Evahmdw by the Local App v vinS AWim* __ Fails Inspector's Sipatun;JV Daft.. ��m inspector shalt sobmit of nle within 30 days�� 5 thi this fiction report to the n8 AWmifty laspoctar and the ecdM� th system e a�system W to or has d p�of 10 Haft,000 ft sty should be sent to the system owner and cooes sent to the buyer,'frf apamnoppfiregimsi and the a of the Not"� s Ong time Thisrepoonlydescribes mat��e of in WP and ender the conditkns of use. system wa1 perform in the fortune of an at that der the same or differ • hie 2 of i l OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY SMMWACE SEWAGE DISPOSAL SYSTEM INSPECTIONY ASSESSMENTS PART A FORM CERTIFICATION(contucM Ptopert7 Address: ,b � � c'P✓ 6 Owner. � > Dare of Ind; o r ft Vftdm S°mmu3, Cbeck AAC,D or E/ ALWAY complete a0 of Sectgon D A. Sy . 1 have not fouad any bftmation which 15.303 ar in 310 CUR 15.304 mm mat any of the fadu�ne exist Any fad=criteria not evaluated am M � ' In 310 C1yR Comment; 'L System Contlidoa»a11y Pam or more system components as k cona repaired,The system capon cow of the�or need to be ZeFfaced or as aXroved by the Board of Health,willAnswer per, ye%no 0r not deter 9.d(y.NM)in me_ far the followi4g If"not d plum 7be Mtc tank is metal WWI ova aanso 4 eduva tiara 20 y s�*or� metal septic tank(whedur not is exdstiag tank is mod with a actration or tank is 0r ) y ��• .System will �the���" afar jhe h3osid of Hesld�, �'°ap°cti°n if the man 20 years old is availabkv and rf a Certf, e ND explain; abseivation of SMp badqW or break out or h%h stabc water le oPl al of or due to a br�4 settled or uaevran mvd in m0 box due to been of Health)' box System WjU_Wu m if(with obo ucd0n s)am mPlsmd s removed �bution box is or ND exgain; The system _ pass if( OftheBOatd of Hameealil a ymr dale to b�or o The System wi11 brolf p*s)am ZePhwed dxftcdm is removed ND explain; Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS SUBSURFACE SEWAGE DISPOSAL ESQ SYSTEM PART A INSPECTION FORM CERTIFICATION a oe no r:� / �1 � ate of of 0 G Further Evaluates Is Required by the Board of Health; &/�Ons exist which require further evaluatiou t l l health,sty emmmign,the Of l��t�l 111 Q t0 the system L System will pass"leas Board e,Heahth es in `+'G system is not to a manner which ppublic wft 310 Q11x ii )tit the health,safety and the endromment: — Cesspool or Privy is within 30 feet of a Suam water — Cesspool or privy is within sp fen of a meted wetlaad or a salt marsh 2. System wM tail Unless the Board system Is l6nctioniop in a manner that Of Re"���water S"ppller,if any)detee m1Ues that the �,safety and envie�o�t: suffm�has o septa� son (SAS)and the SAS is within 100 ta'6utary to a surface water �y feet of a — The system has a septic tank and SAS and the SAS is within a Zane 1 of — TU system has a septic tank and SAS and the SAS is within Sp fed of aXi a Public water supply. The system has a sepW tank and SAS ��watt �' Pie water supply Well".Method used to �tan, 100 feet�t SO feet or nim fim a n PUN if the well water the Pescaft afNckmandvolatile a� cccon4mmis�� ��ell xfmc DEP�MMUM,for coldbrm W=cream am td&Pmd.A copy s»��t lens than 3 Wm,p���and agached to this foam. other 3. Other; Page 4 of 11 OFFISUBSURCIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSE SSMEM FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A RM CERTIFICATION(° Property Addruc S,/,,/ Owner. Date of o 0 System FaUum Criteria, youn�indicate Or•�aPAlica6k to alley�m to each of the folio a'm8forakspections: Yes No se"ap or 1WO bmk or to due to overloaded Or dogged SAS or SAS oessp� the MR&M of the Wound or a waters due to an Static liquid level in the dim box above outlet hwm due to�o�loaded or overloaded or — = yQmd depth in cesspool is less rhea 6" d08�SAS or _ 1 pumping MGM than below invert ar availalc times pumped 4 1° _QMdue to doggy obp (Sow Number Portion of the SAS, or PTV7 is below high Wound 4/ cesspool'or privy is within 100 Beetwater 'or to • teary to a surface — portion of a Cesspool�pp�9� a Zone 1 of a pnbilic wrll, �y Portion of a m 50�of a private wafer supply well. SW*well with or pay is less than 100 fat but S than SO fleet&.a Private water hsdicata that the Performed at&DZP°wed labo P18ble water quality ads. �'�.Pala 11 the wen water analysk wry,for ootitorm and ukrOlm andfn**om or 1 than S f and the presenceo e of � am tr d.A copy of the mew be attached to�am t no other fang a erL (Ya/No)The ormj Health tokave ftmlfued dumbed m�100 CMR 15.303,t �'�m ems.that 000 Of Of the above Wilure ermine what will be necessary to o011W the jh�',owner sbou.W M W��of failunw oLarve� Systems: Qd. considered a system the system muft serve a fadlity with a desks Bow of 10 You mush indicate either W ar.W„ 0 So to iS,0A0 to each of the (The f ollowing CriteriaaX'y to large systems in addition ka above) no system is within 400 fed of a sow&M,24g water�P19 — the system is within 200 ib�of a fr�bniary to a surface�8 water supply Wslem is located 11 of a plc water � (T m wellhead Arr an Am—J"A a a mapped if You hoe "Year Section y won in Section E the system is oonside a 5.3��duest�Simon Em owner or operator� � or answered 04.The system owner should� appaPr late the m considaccordamydthened a Of the Depa • Pa®e 5 Of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PnWdy Ad&vm 356 �� do � Date of Check if the folio foMw=bm been done.You mast indicate es"our"no"as to each of the full Yes -- — B ivbm"cu was proovi&d by the o*vgr, ,Of Board of Health ul- Were aay Of the system cow pmnpDd out in the previous two weeks system nceived normal Saws in the previous two week period — = HAV We vW=m of wVm bm mooed to the �C >000e<rtt�r otr as pert of this Were as bruit plans of the system.obtained and amince aftby were not available note as N/A) — _ the facririy or dwelling in for signs of WwW back up the site hmpocted for*W of&0¬ Were ail system oampoM,=Wn*0 SA$► an site Were the septic tank ofthe ar >staberiei ° 'and tits of the took for the cm t m L 'ft&of hVK&V&of and depth of scram Wnftf � (mdo=*Wbll&ffer+eot from oWmer)provi&d with aaa the proper 1be sine msd bc"m Of the Soil Absorption System OAM on the site has been determined baud ow Yes �o� — — boa.For a plu at the Board of Ifealtb. _ Dt ermi in the .eld(if my of the fgil w criteria related to is ceptable)[310 Chit 1S30Z(3xb)] Pert Cis at issue aWOxiamdon of I Fage6of11 OFFICIAL INSPECTION FORM NOT FOIL vOLUNTAty.ASSESSMN,r SUBSURFACK SEWAGE DLSPOSAL SYSTEM INSPECTION FORM 4 PART C SYSTEM EMItMA1"jOlY Owner. 07 � R 4 o a� REM >tiow coxnor� ¢- ( -3- N=berafbWW... x 3 DFSMfbw-bwed-on.-310.40P.15-203(for.c ,� 110 g�z r 33� Nambtrof : Of Does M lmmdry an a sew�r system .(3^�ar no)• y system. or no)-A)of Yes smar to use. mor no): (yes or no): � Seasonal! Water (jast 2 SnmpPMUP Ou or no):IVO Fps last daft of oy; C011UdZRCL4JJMUSSTBI4LL TYPC of establishawm: Design ljow(based on 310 CMR 15.2(T): Basis of design flow(s=WpcMonWsgR,efc.)• Grease� (yes or no):_ hkk sonal��g tank Pit(yea or no _ NhoW ): w reading,i Ito the THIe 5 system(Yes or no):— Last daft ofoy/um. OTIM(dmcrbe): PumPing Records. G MFORMATION Soarce of imb Was systemPmVed as myes' PronPed:put of gallee�a—flow ar no). / Reason for was y Pumped d F SY 7=f — —Single boot,soil —Overflow cesspow —S>aanOd m CM or m)Cl'ye$attach pre►i Obtained fmm system ownw) Atlach a copy of at cum tray) ice _Tight taah (to be —A�a copy of the DEp _Other(dearke): Approximate age of all c=Vonetk (if 0 Were sewage odors detected when aniviog at the site(yes or no);40 Page 7 of 11 OFFICIAL INSPECTION FORM— SUBSURFACE SEWAGE DISPOSAL A L SYS T FOR, �ARY ASSESSII�N, pAR1,C CrION FORM SYSTEM Property Addnm Il1(FpRMATTON(corma,� Owmer: Am � ms �� 0" Date of bV6 cdoica o � BUILDING SEVER floats on sigelptn) ofaf . L : __1 � Distaaoa pm ate water sop*welt�mom ho,; (an common of joints;vpft�deaoe of I ems): SEPTIC TAM- r(10coo°°site plen) r Hof tim . Mw lftankis nwW3.— le ae confirmed cite) b�'a C 6cate of (yes or nO):_(attach a qoM of X '�? Ps to bottom: ns baffie: a� �� es woe fioom top of sca m.to MP of cadet tee.at baffie:��• How ma oMmliw& af outlet tee ar ixfe. commew(m �>101ed and RIO toad to Outlet:,mrert, e 1: ° as baffle eond b M Y;�a levels �,�'��, vv��1 L•mil H� GREASE TRAP;�� an site Dian) Depth bebw of Material �• ( ): won.— �et®I-= _polyet6ylene_oti�r ems: Scum tb dmca ;_ Distance frmn top of scm to SP ofoudet to or boe: Distance from boaaom of scum to bottom of Date ofIM pumping a tee or bea$ee: as conunam (on�°S 11Dppm O �a aad outlet.tee os outlet�,evideaoa ofleakW cW): �'0 a4 a1. Y, d levels . • . �8ofll OFFICIAL INSFWMN FOI_NOT FOR VOi;D1VTARY SUBSURFACE SEWAGE HWp I;SYSTEM INSPE SMEM PART C ON FORM SYSTEM INFORMATION PrnPerty Addr+em � �u ��✓ �G� Ownw: Date of TIGHT or HOLDING TANX.L(�(tank m�be peernped at , dal gads. t<mecaan sae 1 ) cona+ete_� l moans: ens °��n): Deaign Flaw: Alarm present(yes or no): Alarm kti+el: Date of last m pomp Alarm a"orking�(m ar no): Cam(cone Mw of alarm and flow Wtcb,M etc.): DISTRIBUTION BOX. OPenec>)(locate are sibepaaa) . DqXh of hpW levd above outlet invert l/f J{l-IP7 a G, COmments(note if box is lmd and l�D✓ OWof box,pm): tD a a m9 denoe of solids MY Maenae of PUMP CHAsMM.v on site per) Pamipe in aQ*Wg artier(Yes or no): Ahw=Commeatsm ( g ���). PUMP of pumps need"wftm2cck etc.): c Pa�e9ofII . OFFICIAL PaPZCMN FORM-NOT FOR VOLMTARY SUBSURFACE SEWAGE ASSKSSMXIn PaPEC'Z'Ipx FORM SYSTEM ox(caeti,owi�. owner, y '� DoZ� C Daft of o �� SM ABSORTT'Qp SVSTZK ;_ �s if SAS no bomtid gpip way t _ ovedlow nw�ber:� 4 , : Systm �: etcj� �� � of�— m damps*°° of��� O .' ✓� CES 'OOiSe&OI-' nrmbepampWaspertofink )OOC to an sine pin) Dbw=iMofc=qxML a afoot c Mwe,kW afpooelmg PR1YY: ae sebe Plan) Dimeoeio�c Dcp&of aab� Cow ofs*Sim of cahm kvd afpo e�f eta): Dame 10 of I I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS MEM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM RM PART C SYSTEM INFORMATION Property Addrux ✓ �C N C j v Owner. ot 101 Date of SEETCH OF SEWAGZ DISPOSAL SYSTFJ�um,M Provide a stretch of the sewage&spy . bertawa .Locate an wells within 100 feet, mcbjdlq8�to at ae two p rete � t'.oc�te where pots water watler snppty enters the bang, a ��- a/ , J I Page 11 of I1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DLSPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(comma Pn)perty Addreic // x 4a4r1�� ® owmr. CPC419 Date of o CNC f snz EXAM Xo, r skqz udwe water ( � _ 9 , 5 Check� Shallow welts (o&n�te r - 02 ' 9Ali / dqA to So and water=feet plem (CbOCIC)an methods used todo=jue the hghItmuad water dr atio; tamed� o ' ho� �I date of des�gs,pian � C,b,�����o( withioa ISO fiaet of SAS) , Aooessed ears,mstaitm(atfachn) Y y� the ..3 d � 0 water dr, L okn (ro ©y ot0 j s aO O/ Jl0 o 4-1 rare C �]�JtiSTvhev► CIAC e ,4,., RCi or o20 0 , a 4 4e .5���, aL ✓to �e�/e c-�- fAe A,fo � S " Soec , &0 tire- s 1yo 0 c 2ia� c0"