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Home My WebLink About0042 WOODBURY AVENUE - Health ;9,WOODBURY AVENUE, HYANNIS A= 307 073 No. 10 'U I Fei THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for disposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon X ❑Complete System ❑Individual Components Location Address or Lot No. 4A WOoppUPy Ali IF Owner's Name,Address,and Tel.No. HYA001S DZ(Ar4lS 4P LOV Assessor's Map/Parcel 67 w000gggu 4VE A Installer's Name,Address,and Tel. o. 502—4 77„$ 7$'� Designer's Name,Address,and Tel.No. dAP&Q b ,T ES� N/A 15 <!Aw g-r_ 5T NASOP615 Type of Building: nn Dwelling No.of Bedrooms Lot Size (25`Ac? sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board Qf Health. Sigq4, h . Date a—t$-010tq Application Approved by Date PL p(V Application Disapproved by t IV Date for the following reasons Permit No. —0 / Date Issued ft of THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s Yes PUBLIC HEALTH DIVISION -TOWN OF'BARNSTABLE, MASSACHUSETTS Zipplitation for Vsposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(K ❑Complete System ❑Individual Components Location Address or Lot No. 4A WOODpUIL-`/ Atli Owner's Name,Address,and Tel.No. HYANN(S 07_(Af41S ARtOv Assessor's Map/Parcel O7 1673 4:p— uP—y 4VE A Installer's Name,Address,and Tel.14o. 5CQ.-477-8%-T7 Designer's Name,Address,and Tel.No. c A PCW(1E N 1A 1' G-A1 c1 W_ sT M D 619� Type of Building: Dwelling No.of Bedrooms Lot Size 19- oZq S sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S Description of Soil Nature of Repairs or Alterations(Answer when applicable) �II A Am boD ) StSF7 r-I e_ j 1�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date a"t R"c�.0 l 4 Application Approved by ( �a h Date Application Disapproved by Date .for the following reasons Permit No. �f Date Issued o/ / THE COMMONWEALTH OF MASSACHUSETTS �,,d 0,A vAAt c�;, BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-siteSewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(X)by CAPEu�f a C— G�J lZ t7fE�lSES c.i l . at 4a WJoa )Pjugw Av;5 HYAL)y(S has been constructed in accordance with the provisions of Title 5 and the for Disposal System {Construction Permit No.c�01 7'0�t dated / G� Installer(2AP&"i bL &JT5XJ_ 'K&-5 64< ,. Designer NIA #bedrooms Approved design flow IU�i� gpd The issuance of this permit shall not be construed as a guarantee that the system will fit ction as desi e•. Date r L�— Inspector ---------------------------- -----.----------------------------------.-----_ - - --------------------- ----------------------- No. )0 t q-0 /j Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at 4d, w00bb U gy AVE i4 YA 10JI S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe it. Date 7 I �I Approved by l I .V J d r TOWN OF BARNSTABLE LOCATIONS WOODBURY AVE SEWAGE # "� VILLAGE HYANNIS ASSESSOR'S MAP LOT O� INSTALL ER'S NAME PHONE NO. ELLIS BROTHERS CONST. CO. 362-6237 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS---L�_PRIVATE WELL OR PUBLIC WATER___ BUILDER OR OWNER y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C� Ile Yo ...... ` s � - _ Fa .. .......b. tea THE COMMONWEALTH OF MASSACHUSETTS RpwEo BOAR® OF HEALTH �G e 9Wn CW=rX*M artmentTOWN OF BARNSTABLE �3 Workii Tonfitrnrtinn Permit e Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal Syst at- 1s C/ ��nr-ttii \ddre / �� Or Lot/� -------------�fl �/1 ---------._..-._.... ------ O, er ddrEss Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.................. Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------ ---------------------------------•---------------•--•---•----------•--...._..---•----------------------•---•------------._....---••-------•••---•----- 0 Description of Soil......................................................................................... ------ ................................ ---------...--•••---•---------------• U ----•--------------------------------------•----------------------.._._...•-•••--•------------------•-----------------•-----------•----•----------------------•-••••----....---.......----------------- W --------------------------------------------------------------------•----------....-------------------------------------..-...----•------- �-} U Nature of Repairs or Alterations—Answer when applicable.--_ ...Q�-�J__._Z ....__.s .___ •-- --...----•-------------•--_. ...----........_---•---- 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 hass been issued by the board of health. Signed s%6 �' E== ` " �'o��'`m� .......... - ........ ........... ............... ........ - ApplicationApproved B ._.. -.. . .....��....�-�.��..`�✓�'...... .. ....._........ .............:. ................ .. ....---------........._....-......-.... Dace ..- -..... Application Disapproved for the following rearons: . ................. ............. . .. ... .. ........-. ..............---........... --............-.......... ............................... . ................ ..........-........................... - - ......................--..............-..-...-..-......- ........................................ Permit No. .......... 7-......V e -�.... ....... Issued ..............�.- F�.. ce ..................... ...... ...... Dare I /-�V �a.l� :s a C ! t•� � � k. y\N�> �V i'��•C.. % i.J'-. T w THE COMMONWEALTH OF MASSACHUSETTS` J BOARD OF HEALTH TOWN OF BARNSTABLE liratiun for DiriVaii l Wurbi C omstrurtiun ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: , Locatiotw \ddrc' -.or Lot N 9A— ! r l /l `f Z� ..�/..� ...... ........ !- ... L/ Address Installer j f �} Address UType of Building ! Size Lot..__•............... Sq. feet .� Dwelling— No. of Bedrooms------------------ --------_---------___Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building -------------------------L No of persons----_______________________. Showers ( ) - Cafeteria ( ) p' Other fixtures .. r 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 ( ) J a Percolation Test Results Performed by.......................................................................... Date........................................ i' Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f.4 Test Pit No. 2.................minutes per inch Depth of Test Pit---------f........... Depth to ground water........................ a ....•-•--•••-----------------•--•-••••••---••••--•••--•-••-•-•-•......•••••. ............--••--.......................................................... ODescription of Soil......................................................................................•----------------------------------------------------------------...........--••- UW ••-•••-----•---------------------•-•----•--•----...----------.....-•••--•........-•----••---••--•-------••-•----•----•----------------• -•-•-•-•-•••---•------------•--•--••--•-•----•-— Nature of Repairs or Alterations—Answer when applicable.___ .�d ... G_._.S.t....... �7` ci7.._ _ 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 been issued by the board of health. f '� � DSigned ...........'............ .................. ate. . .-----.......................... ......._ Application Approved B</ G Application Disapproved for the following reasons: ....................... ....................V:............................................ . .:........................ --- .............................. .......................... .................................... ... . . ................................ ..... -- . ........ ........................................ Q to .Permit No. .....1...... ------...........................:....... Issued ............................................ ........ ... ' Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Cnomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b .�41.... .5.-..� s.7`'.......... at ............. .... ..----- ....... ... --------- - .... -- ---------------------:.... - _... has been inst lied in accordance with the provisions of TI"f1:E of The State Environmental Code as described in the application for Disposal Works Construction Permit No. '...'��.. �....... dated .7.-�.... .�> THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................_f....�.� ?.:-.......�....�-/�. ... .............. Inspector -�... ...... _............ ...... ........ _/" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE3;_c) --.....°........ Mipood Worse Tnnitnuli.an "antit Permission is hereby granted.......... . 4,4".J to Construct 1 r Repair ( an Individual Sew a /e Disposal System Street as shown on the application for Disposal JWorks Construction Permit --------------- ' .... � --------------------------------- - ----------- �� IIoard of Health DATE................ = .....----•-••---...--- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS Appraisals Plus,Inc. SKETCH ADDENDUM File No. HY703009 r Case No. • Borrower Arlou- Property-Address 20--WoodbuN City Barnstable County Barnstable State MA Zip Code 02601 Lender/Client American Home Mortgage Address 2 Oak Street,Mashpee,MA 02649 Note:Not to scale 30 1l7 Den Bedroom 10' r 14 Bedroom 15 33 Bath K W r Kitchen - Family Roam Den Bath Dining 24' 14' 10 Bedroom Living Room 30 ` ClickFORMS Appraisal Software 800-622-8727 Page 4 'of 11 f' 7 �t 1 . Remodeling kitchen 2 . Remodeling 2 bathrooms 3 . Create 4' by 3 `opening in wall between living room & kitchen 4 . Change 2 single windows to one mullion unit in living room 5 . Remove & replace sheetrock in entire first floor 6 . Insulate all exterior walls T. Create 2 closets : one in bathroom, one in den . P-.e la- C-e sle Kt"�Ilove 1 ` Appraisals Plus,Inc. '" SKETCH ADDENDUM File No. HY703009 • Case No. cLeLqnt Arlou Propertyress 29 WoodburyAve. stable CountyBarn table State MA ZipCode 02601 American Home Mortgage Address 2 Oak Street Mash pee,MA 02649 Note Not to scale 30' 10' Den Bedroom 10 14' Bedroom 19 3, Bath 30' Kitchen Bath Family Room Dining 24' 14' 10 Bedroom Living Room 30' ClickFORMS Appraisal Software 800-622-8727 Page 4 of 11 r 1� TO ALL NEW BUSINESS OWNERS DATE: - a Fill in p ase: � r APPLICANT'S YOUR NAME: t'd r BUSINESS YOUR HOME A DRESS: tA yd Tel hone Number Horne TELEPHONE k Y NAME OFII;W BtISINf�SS T PE;OF BI.SINESS � IS THIS A MNNE +C?CUI�ATI4N' Y>.�S NO ],]eve,. „rova�. rm-the brildin d[�ris' fr'? YSIUO�. .. ;. :- .... : AI bR5S::4i ;PSI N~.:: .: : ..,. ,.:' IIIIJm�.R When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you.may need. Once you have obtained the required signatures, listed below, you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall) or if you get the business certificate first you MUST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St. —(corner of Yarmouth Rd. & Main Street) and you will find the following offices: 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has be n inf ed 9f the permit requirements that pertain to this type of business. Auth6rked Signature*" COMMENTS: AZ f 'i�--Qo o f L 0 c rLve�, 3. CONSUMER AFF RS (LICENSI G AUTHORITY) This individual has en informed oithe licensing requirements tha ertain tothis-type of, iness. LI ut rized Signat re** ✓� COMMENTS: Business certificates (cost $30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. - it does not give you permission to operate -you must get that through completion of the processes from the various departments involved. **SIGNIFIES APPROVAL FOR A BUSINESS CERTIFICATE ONLY. Date: � 01-71 /d� r TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS:! it mn d ::raSCL BUSINESS LOCATION Gt)6odBVU LI PWQ H"Ur.r1Ai<, mn . aZL)l INVENTORY MAILING ADDRESS: SIMC Q S «.hnto TOTAL AMOUNT: TELEPHONE NUMBER: " -790-- CONTACT PERSON: Zj)a i Q i Ci ::X< a f(e-j m stnd EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS:'Ta)(f 5. V-u lees INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED Nib (insecticides, herbicides, rodenticides) liliq Gasoline, Jet fuel, Aviation gas rIl Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED _r IL Degreasers for engines and metal Printing ink AIP Degreasers for driveways &garages Wood preservatives (creosote) / Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes VJA Other chlorinated hydrocarbons, AA Lacquer thinners rn I (inc. carbon tetrachloride) NEW USED ' v Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, I� Misc. Flammables hydrochloric acid, other acids) A Floor&furniture strippers Other products not listed which you feel qII Metal polishes may be toxic or hazardous (please list): !V Laundry soil & stain removers IyDZ fa. r't (including bleach) L QW5 &(0QQ+ 4 a_"a A r Spot removers &cleaning fluids (dry cleaners)— Other cleaning solvents �J Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M S., y 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every 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. Important:When filling out A. General Information forms on the �J computer, use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name P.O. BOX 2384 Company Address MASHPEE MA 02649 City/Town State Zip Code 508-221-5003 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. 1 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 AL P-A,�� , 1/26/07 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 syitem,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 conditionscof use at that time.This inspection does not address how the system will perfo in the uturetu,nder i the same or different conditions of use. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is HYANNIS required for MA 02601 1/26/07 every page. CitylTown 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) Syst 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. 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 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 0260.1 1/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 115 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 ❑ L�`�,/ Discharge or ponding of effluent to the surface of the ground or surface waters / due to an overloaded or clogged SAS or cesspool ❑ Il_Ji/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ tell Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ LK� 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. 281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GN s 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name requirnformatifo is HYANNIS MA 02601 1/26/07 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ E/ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ZI/ 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 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. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is HYANNIS required for MA 02601 1/26/07 every 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 ❑ L�1 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? ❑ E?"� 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? ❑ MWas 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)] 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is HYANNIS required for MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: 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 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 9/No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes Vo Last date of occupancy: Datetj or Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present?' ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M , 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name General Information Pumping Records: Source of information: 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 0 Were sewage odors detected when arriving at the site? ❑ Yes No 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is HYANNIS required for MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1 Depth below grade: feet C Material of construction: Last iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: � In1 t�c � feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: t feet Materi I of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: o Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 1 Uc How were dimensions determined? i 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is HYANNIS MA 02601 1/26/07 required for every 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.): (� c C4 ci Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 1 n C t�t/�Trrt1 Pump Chamber(locate on site plan): ,Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number. ❑ 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.): <<-- 1N`o v a V\j a 281OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M a 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 0 d f L 32, -63- la 0rS'3 3L 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 29 WOODBURY AVE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owners Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: S;,/Check Slope Surface water Check cellar UK'Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: ILA ( ?, (Li lnrt`c aNQ-e�tc WTiaris You must describe how you bstablished the high ground water elevation: 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 C N� TOWN OF BARNSTABLE LOCATION 29' WOODBURY AVE SEWAGE # U VILLAGE HYANNIS ASSESSOR'S MAP & LOT Q7 INSTALLER'S NAME & PHONE NO. ELLIS BROTHERS CONST. CO. 362-6237 SEPTIC TANK CAPACITY 6"'jo-e LEACHING FACILITY:(type) 7 (size) 10etp NO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER CHART TF nnpUiily DATE PERMIT ISSUED: '7 DATE COMPLIANCE ISSUED: —/- aj / 3 VARIANCE GRANTED: Yes No ,. . . �` `, .�'�"- � t� � � /'-��!. � \._ � ., f Commonwealth of Massachusetts ' 419 Executive Office of Environmental Affairs NOV 1 19 y0 Department of Environmental Protection r William F.Weld 507 S TrudyCor oxe 0`23 Secretary, %XEA David�hs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 14 9 Wov a ` c Address of Owner. ?�( �t-�-y� v•,c.z�.v �D�t Date of Inspection: (If different) Name of Inspector Company Name, Address a� ne Number: � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 3v— 9._�� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original shouid be sent to tine s}stem ov.ner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYS M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined', explain why not) The septic tank is metal, cracked, structurally unsound,-shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised S/iS/95) One Winter Street • Boston,Massachusetts 02108 • FAX(SM SW1049 • Telephone(617)292-5500 Printed an Recycled P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:'")v Owner. Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION 15 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface 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 APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil adsorption system and is within iOO feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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• DI SYSTEM FAILS: 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a 9 Owner. Date of Inspection: D] SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy,is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. '' Date of Inspection: 10��'7—�S� Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rases. Z- As duri that period. Large volumes of water have not been introduced into the system recently or aS part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A. Ze facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow V he site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. VThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or Zhe material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ize and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. V The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 wcrt to 1 �� Owner: Date of Inspection: /0-,;2 n— C1 S FLOW CONDITIONS RESIDENTIAL: Design flow: b gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no): Nb Laundry connected to system (yes or no):&5 Seasonal use (yes or no):A/a Water meter readings, if available: Art) Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_�W J. If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy hared system (yes or no) (if yes, attach previous inspection records, if any) APPROXIMATE AGE of all components, date installed (if known) and source of information: YA Sewage odors detected when arriving at the site: (yes or no) � (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: '? W cry �( aL4x Owner: tc,.9,,4 irti Date of Inspection: / —ate�—g S SEPTIC TANK:_ (locate on site plan) Depth below grade: /6 Material of construction: concrete_metal _FRP other(explain) Dimensions: /V X �y" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: / 04" Distance from top of scum to top of outlet tee or baffle: f Distance from bottom of scum to bottom of outlet tee or baffle: Tc Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) —T GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ni -c`um.to bottom of outlet tee or battle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a;2 �*n f ° Z)'^a , Owner. c14" Date of Inspection: TIGHT OR HOLDING TANK:_ ' (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: 410 Comments: (note if level and distribution ;s eq�ja!!{, evidence of solids carry-over, evidence of leakage into or out of box, etc.) Y PUMP CHAMBER:_✓U (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc) (revised 8/15/95) 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address '!v Owner. Date of Inspection: ! A-7— P S— SOIL ABSORPTION SYSTEM (SAS): , by non-intrusive methods) (locate on site plan, if possible; excavation not required, but may be approximated If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: �i,Gl-'-!' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) �n/a -j — CESSPOOLS: 1UJ (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 groundv.ater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (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) (revised 8/15/95) 8 • L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: o2 Owner. Date of Inspection: _ a r7_ ,r SKETCH OF SEWAGE DISPOSAL SYSTEM:- include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I DEPTH TO GROUNDWATER Depth to groundwater. •33 feet method of determination or approximation: � a U s C (revised 8/15/95) 9