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HomeMy WebLinkAbout0546 STRAWBERRY HILL ROAD - Health L546STRAWBERRY HILL .F 1 a. Hyanni s � A= 249 - 167 ` ° Y e ° K t ur o s TOWN OF BARNSTABLE LOCATION Sy(o 5tr«wberry Nl i( SEWAGE# 2,000-201 VILLAGE H ann ASSESSOR'S M 'C& �L ZH9�I l�7 f 5 t AME&PHONE NO. Accu Sepcheck 17 Northside Dr. SEPTIC TANK CAPACITY 1000 gal S. r)pnnm- W Q ram' _ LEACHING FACILITY:(type)'_ T I 11(ssiize)0 lj a �1 r tJS li NO.OF BEDROOMS .OWNER E d a, Char C G PERMIT DATE: �0 l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Z® 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 B� //1/� S - 1 a � O � W W A r U � W N �� Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �l M 546 Strawberry Hill Road, Hyannis, MA Property Address p Edgar, Charles 8 Countryside Drive °°� Owner Owner's Name w information is required for every Chatham MA 02633 10/12/2017 a page. City/Town State Zip Code Date of Inspection � ? Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms # r a(0 on the computer, use only the tab 1. Inspector: key to move your cursor-do not. Joseph M Martins use the return Name of Inspector key. Accu Sepcheck Comp Company Name 17 Northside Dr Company Address South Dennis MA 02660 Cityrrown State Zip Code 508-385-5891 SI 147 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The 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 10/12/2017 spector'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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 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: SEPTIC TANK OUTLET EFFLUENT FILTER WAS REMOVED CLEANED AND PUT BACK IN PLACE. SEPTIC TANK INLET TEE THAT HAD FALLEN OFF WAS REPLACED W NEW TEE. BREACHED PORT IN DBOX WAS PATCHED. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional ss"section need to be replaced or repaired. The system, upon completion of the repla ment or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the eptic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltratio or tank failure is imminent. System will pass inspection if the existing tank is replaced with a c plying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if' is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is le than 20 years old is available. ❑ Y ❑ N ❑ D xplain below): f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with oard of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static wate evel in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or neven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced Y ❑ N ❑ ND (Explain below): ❑ The system required pumping re than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if( ith approval of the Board of Health): ❑ broken pipe(s)are r laced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is re ved ❑ Y ❑ N ❑ ND(Explain below): 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 t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is Chatham MA 02633 10 2/2017 required for every page. Cityrrown State Zip Code to of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Publi Water Supplier, if any) determines that the system is functioning in a manner at protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption stem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to as ace water supply. ❑ The system has a septic tank and SAS and th AS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and a SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and a 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 a lysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 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 sys must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"ye "o no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is 400 feet of a surface drinking water supply ❑ ❑ the sys m is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ th ystem is located in a nitrogen sensitive area (Interim Wellhead Protection rea—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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 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, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 I DESIGN flow based on 310 CMR 15.203 (for example 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is Chatham MA 02633 10/12/2017 required for every page. Cdy/Town State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK, DISTRIBUTION BOX, LEACH PIT W STONE AND 2 500 GALLON FLOW DIFFUSERS W STONE Number of current residents: 0 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 ® No Water meter readings, if available last 2 ears usage d 101 9 ( Y 9 (gP ))� Detail: 2015: 35,000 G 2016:- 39,000 G Sump pump? ❑ Yes ® No Last date of occupancy: 8/31/2017 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. City/town 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: PER BARNSTABLE HEALTH DEPT: PUMPED MAY 2000 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•3113 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 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NEW LEACHING 2000-17 YEARS. TANK AND PIT 40 YEARS ORIGINAL 1977 DBOX UNKNOWN NSTALLED Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments (on condition of joints, venting, evidence of leakage, etc.): FLUSH TESTED NO LEAKS . HAS SEWAGE EJECTOR PUMP IN BASEMENT BATHROOM IN WORKING ORDER. Septic Tank(locate on site plan): Depth below grade: 1 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: APP 8.5X 6X5 1000 G Sludge depth: 6" � t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 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 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6' Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? CORETAKER Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): MISSING INLET TEE SIDE ENTRY-WAS REPLACED BY INSPECTOR . HAS PVC OUTLET TEE. LIQUID LEVEL IS 48". NO EVIDENCE OF LEAKAGE. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or ba a condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at ime of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ 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 f alarm and float switches, etc.): M *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is Chatham MA 02633 10/12/2017 required for every page. Cityrrown 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 AT INVERTS 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.): PATCHED BREACH IN DBOX. FLOW DISTRIBUTION IS EVEN . BOX IS INTACT. NO EVIDENCE OF SOLIDS CARRYOVER Pump Chamber(locate on site planyber, Pumps in working order: El Yes El No* Alarms in working order: El ❑ No" Comments(note condition of pump cition of pumps and appurtenances, etc.): N/A "If pumps or alarms are n in working order, system is a conditional pass. Soil Absorption Syste (SAS) (locate on site plan, excavation not required): If SAS not located, expl in why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6X6 W STONE ® leaching chambers number: 2 500 G W STONE ❑ 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.): BOTH SAS ARE DRY. 500 G HAS STAIN LINE OF 8"OUT OF 24'AVAILABLE. LEACH PIT IS DRY- NO DISCERNIBLE STAIN LINE BUT IS MODERATELY STAINED YET STONE IS CLEAN. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A 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 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, lev of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition f soil, signs 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 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. Cityrrown 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 Ej drawing attached separately Sfi�LAW%Q R`( N 11, tZ 17 NSTA N C E5 Al = 31.5' QI - 1 H I AI G2- 12 19r 24 = 27.5` C4 - 3S-t r g5 `12 c S' Z W C A B 3 00 z 1 N T'S t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 30feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: GOOGLE MAPS, CCC GROUNDWATER COUNTOUR You must describe how you established the high ground water elevation: SITE IS 63'ASL. POND CONTOUR IS 27'A SL . MAX RISE IS 8'. GRADE TO DEPP3EST SAS IS S 9.4'. SEPARATION MATH : 63-(27+8+9.4)=20.6 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 Wy y„e °< 546 Strawberry Hill Road, Hyannis, MA Property Address Edgar, Charles 8 Countryside Drive Owner Owner's Name information is required for every Chatham MA 02633 10/12/2017 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Ali, ��'` + Yc . k"��� •�� °..<.... V9yWjl'' �r:' yy v�i. °� '�'� "t i r R {�' '$ r t Y. t1.4` q < 4u'+ a J :..i '. �` '� pw, � e♦. G }�+ - s x � fir'l,.+s lk Ar *ems!•' � �- �'�N� �- r r,� r rA'xr � •.s r .- "� r �',µ •Y•�����7l1 ��'• ,.R'w. � `5.' J �y��" l f.#ry.T�1� li�I • 3 f W'sa ' j ��.�i +.P,s3 ,♦ �� --^ '`�7'* 0, •ev �"` �, }fir w _ � R k . • f V 4�t ��� •i y,Y�•..�.� < � w� K+��+g�y � CJ.<den �10 .� /<� �r �� + 1.r• ,.ram' � + _ � �¢�C �v+l�p ��1 ���.,'� ., L � v.< i , C``' t <k>.°K�i`e iw syw' 3`n''• r f! 9. _-, J 4l, ' . 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