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HomeMy WebLinkAbout0059 LOVELL'S ROAD - Health 59 LOVELL'S ROAD, COTUIT A=025-19-1 �l 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. CitylTown 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 A. General Information (� 1 forms on the 5051 J computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 If Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification certify that I have personally inspected the Y sewage disposal system at this address and that the P 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 L 7/6/09 Inspector's Sig re 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. 6 7 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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: The septic system is in proper working order at the present time. 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. 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 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ _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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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 soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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 %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. City/Town 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. El ® 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 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ 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 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,distribution box and a 12'x38' leachin field. Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use. ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2007:98,000 g ( y g (gp ))' 2008:270,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: Tamk pumped 4/20/09 for maintenance. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ' Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): 101+ Distance from private water supply well or suction line. feet Comments (on condition of joints,venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: E 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: 1500 gallon Sludge depth: 1" t5ins•09/08 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 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. City/Town 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 31" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 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.): 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): I 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M ,••'' 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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 No 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.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit. Ma. 02635 7/6/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 12'x38' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching was dry at time of inspection. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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.): 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.): t5ins•09/08 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 59 Lovells Rd. Property Address Paula Fay. . __ Owner Owner's Name information is COtUIt required for Ma. 02635 7/6/09 every 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: I " ❑ hand-sketch in the area below ❑ drawing attached separately n I � oa t5ins•09108 Title 5 Official Inspection Forth: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 ,M 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every 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: Bottom of leaching 20'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: 1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 late#2 annual ranges of P 9 groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 59 Lovells Rd. Property Address Paula Fay Owner Owner's Name information is required for Cotuit Ma. 02635 7/6/09 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I � Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611612000. Inspection forms may not be altered in any way. A. Certification -dU 1. Property Information: 59 Lovell's Rd C-f a Property Address Paula Fay Owners Name 52 Lovell's Rd. Owner's Address Cotuit MA 02635 City/Town State Zip Code Date of Inspection: 9128106 Date 2. Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 City/Town State Zip Code 508.272.6433 Telephone 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 the inspection. The inspection was performed based on my training and experience in the proper function and mai tenanc"f on site sewage disposal systems. I am a DEP approved system inspector pursuant to S tion 1!�34W Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails UO Ln - ❑ Needs Further Evaluation by the Local Approving Authority y 9128/06 ` w Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authontl (B 'd of Health or DEP)within 30 days of completing this inspection. If the system is a ared 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. 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,V Subsurface Sewage Disposal System Form b A. Certification (cont.) 69 Lovell's Rd Property Address m Cotuit MA 02636 City/Town State Zip Code Fay 9128106 Owner's Name Date of Inspection 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: A portion of the leaching field is under the driveway. OK per health agent on 9128106 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: n/a 59 Lovell's Assist2 sell.doc•11/2004 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) 59 Lovell's Rd. Property Address Cotult City/Town State Zip Code Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a 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 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments lug Subsurface Sewage Disposal System Form A. Certification (cont.) 59 lovell's Rd Property Address Cotuit Cityrrown State Zip Code Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(coat.): 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form A. Certification (cont.) 69 lovell's Rd Property Address COtu%t Citynbwn State ZipCode Owner's Name Date of Inspection 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 '/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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine What will be necessary to correct the failure. 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts . Title 5 Official Inspection Form p . Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 59 Lovell's Rd Property Address , COtult Cityrrown State Zip Code Owners Name Date of Inspection 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 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form B. Checklist 59 Lovell's Rd Property Address Cotuit City/Town State Zip Code Owner's Name Date of Inspection 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(3)(0)j 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts ugTitle 5 Official Inspection Form* Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 59 Lovell's Rd Property Address Cotuit Cityrrown State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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: Last date of occupancy/use: Date Other(describe): 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 59 lovell's Rd Property Address COtult City/rown State Zip Code Owner's Name Date of Inspection General Information Pumping Records: Source of information: 1112 yrs. ago per owner 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: 1997 per as built Were sewage odors detected when arriving at the site? ❑ Yes ® No 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 59 lovell's Rd Property Address Cotuit City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 8"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10+ft. feet Comments(on condition of joints, venting, evidence of leakage, etc.): No adverse conditions Septic Tank(locate on site plan): Depth below grade: 2"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: n/a years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ 'No certificate) Dimensions: 1500g Sludge depth: <619 Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 1/2" •Distance from top of scum to top of outlet tee or baffle >21. Distance from bottom of scum to bottom of outlet tee or baffle >2" Now were dimensions determined? measured 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts UuTi tle 5 Official Inspect'on Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 59 Lovell's Rd Property Address Cotuit City/Town State Zip Code Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No adverse conditions at this time. Pumping recommended every 2-3 yrs. to prolong the life of the system 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 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: n/a Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts ' Title Official t e 5 ®ff c al Inspect)®n Form ° Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 59 lovell's Rd Property Address COtuit Cityrrown State Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: n/a Capacity: gallons • Design Flow: • gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: El Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level w/bottom of the pipe Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box is 1 V below grade and no adverse conditions exist at this time Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No ' 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System i Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 59 lovell's Rd Property Address Cotuit Cityrrown State Zip Code Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 16WO' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Perf pipes Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no adverse conditions at this time 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System- Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 59 Lovell's Rd Property Address Cotuit Cityrrown State Zip Code Owner's Name Date of Inspection 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 Q 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: n/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments lug Subsurface Sewage Disposal System Form C. System Information (cont.) 59 Lovell's Rd Property Address -Cotuit Cityrrown State Zip Code Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the 9 high round water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1997 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: You must describe how you established the high ground water elevation: see above 59 Lovell's Assist2 sell.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts a Title 5 Official Inspection Form x° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 59 Lovell's Rd Property Address Cotuit City/Town State Zip Code Owner's Name Date of Inspection 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. ------------------- 2A L`-( r l 6<< Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System TOWN OF BARNSTABLE a LOCATION f!t!2 "U CL SEWAGE # VILLAGE '�� ' � ASSESSOR'S MAP& LOT��—_ INSTALLER'S NAME&PHONE NO. d3h 7"� / l.cf/ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER Pt 7 PERMIT DATE: A a—9 V COMPLIANCE DATE: 14 / Separation Distance Between the: M Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching cility) Feet Furnished by 0 d �6 / well No. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS Z(ppliCAtion for Mizpozal *pgtem Cow6truction Permit Application is hereby made for a Permit to Construct(V)or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. /, � � -9waas-Pd�tfe Address and Tel.No. u 4 (Ja ) -PA L)LA � `h i a tit a corulr s�Lot��(tts ��. C�u). LoVC-Lj_s izr, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. p�4xT1='L: + #Je- 017- M A-14 STr £?5 1 Type of Building: Dwelling No.of Bedrooms .3 Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3.30 gallons per day. Calculated daily flow 130 gallons. Plan Date JAA `Z. l 9 q-1 Number of sheets 13 Revision Date Title C.MT1 F%31:) PLO ALAN 114 LOru rr 5C-Atz 1'�4a wrz EhVL,a + DiA W S AAA y Description of Soil © ��/fv"E" /L��J 3G"8 ��� 9 MaQ,;a" SAyo 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 wiih the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by.-this Board of Hea Signed Date q Application Approved by i Application Disapproved for the following reasons Permit No. Date Issued " % ..!-..^ ,'r,..` Nam•.vY . .J ♦II. .n .. r �_ , MATS r !'Ct+� 1 +--I No. ..�X Fee / , L — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE, MASSACHUSETTS 2ppiicart%on for 33izpaal *pztem Construction 3dermit Application is hereby made for a Permit to Construct(V)or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Otir r=s-NAmz Address and Tel.No. VIA Corvlr . Sq 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. O 4 14•IL ." f' Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design,Flow O gallons per day. Calculated daily flow 560 gallons. Plan Date A N 1Z, 1 9 9-7 Number of sheets . 3 Revision Date Title C;aT1 Ft grz) Pwr PLAN 114 601V T 5C A .& I AQ Foe ?P QLA + ►'7, tp tJ E F7A`( Description of Soil 0-d'11 0 (, �/6 s" lk -,ale 11Z A — 9 /6/aOIL)4ft SANd �. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: J 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 Certifi- cate of Compliance has been issued b this Board of Signed Hea 5e.lco�� Date 3 q Application Approved by t Application Disapproved for the following reasons Permit.No. ��-� / 2 Date Issued Z THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - -` THIS IS TO CE�,TIFY,that th On-site Sewage Disposal System installed(14or repaire replaced( )on by �f � fori6�9L -� .AYJsA� as / ZZ7� —4�- 7. has been constructed in.accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: No. Fee/A'0A THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ;ioogar *p.tem Con!5truction Permit Permission is hereby granted to iy�7 to construct (V)repair( an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction/must be completed within two years of the date below. Date: / �G�t '� Approved y' v — b�•SIU-L �ATa rll,l�l.>r F/SMII.`{ 3 F3�R�� �E pL.A I-1• otil BAGIL uErzE•� Flo GA¢�3AL� Gw��. LOT ��_� MAP z5 MAU'i �t.ow = 3 x IIo = 330 � QoA� CoT'o 17 Sync TAN L = 3,io )(,Zoocri!e.E..Svo%_&6o 6►�- u�F IC700 6AL• Iti 1z I2'x 36 LcAa ,&r.f I GA-00t 4 AMA ���D• I I 440 SF• t=zR I a 4' ,tPP uusToN AVZA D�51b N I A + •� A A = 45&sF orroM -Topv_ A;r4 ,4s4o Iv Imo{ ' soli I SN OF �� PETER °,CHARD SULLI4APIA. ' eAXTR NO.29733 I L o L,=,�0 F i EU> Vo 2048 A CIVIL �" � t✓ T�- !o� �EMOv a Mr. �EA[ IOU 53 � 7 M6D• � Saab [c fli�N waTce c� I%. war» t-t,- s Tlt�l �oTv1'T' p 6e2zo cam: !2 i�2 9!� S6.L� I'� 2,1�19"1 •bw�w1►�L 51-awN PLAU R�-Y�tJl� I Ls=F`f 'C-�WT w� T� V�.uN� AI.D ��pN CAMpt.`15 d;6T5A-V— MOVIZEM69T DF T'46 70K/IJ OF MAP 2y PAPG�I— I`f'I --aAR,N STA9 u P-* 15 tkT- L L�G11'T�D W l T,I N A Nym I wr- �a4L FLt�vD NAZAI�D ZONE• �{41JD SU�I'sYQu • G�1G1�16I=� 2, 101 "1 ci Q � oST�zVlu..6 Md55 5 s VV-oN1 BVIC.D1I.1l�S S�ice" B>=. Arp JCAN4 r. RoLA �' bIA4& fiat L>z eD Tb r,-�Bu s%A PROpE�•1`1 97 ti►aP 25 Pcc �9-/ ZF/wP 37 72 411 1 \ /t 1/2 , OF!M��4 , QIWAPD BuTER two awd �� II �' •,�� I � Ir� i i 1 �sTt 4 vAOF W l PETER SULLI 1AH \r ,re H0.29733 \ > y Z CIVIL ` e I V 4 � l- 2.4"� �r FAvLA f DlAv6 FAY PQ Lwe PLa a . J W6 �Gu S J L r- 1 G O Weil.- 1� LOry►T" W�-n�s�u�T \? L \ d m r W rw' I 1 � � pO 1 � 1 M&:, zs L lq tN OF oA..an K070 H�' vo a�o+e x 1 13 ,S ..._ r I TOWN OF BARNSTABLE a LOCATION t Lo V elk �p�p SEWAGE # VILLAGE -T-U t _ ASSESSOR'S MAP& LOT l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING".FACIUN: (type) T7t e (size) /a>e 38"l NO.OF BEDROOMS 3 BUII,DER OR WNER T—N 7 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: MaximtnTi Adjusted Groundwater Table and Bottom of Leaching Facility S� 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 30U feet of leaching cility) Feet Furnished.by V� I 1 _ v I � 9