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HomeMy WebLinkAbout0034 HAMDEN CIRCLE - Health 34 HAMDEN CIRCLE, HYANNIS A= 291 185 11-7 l8-5 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir M Property Address Linda Rowell V Owner Owner's Name information is required for every Hy annis ✓ MA 02601 11-23-16 a page. City/Town State Zip Code Date of Inspection W m 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. A. General. Information 57* /ADS(,a 1. Inspector: , Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify That I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Eval on by the Local Approving Authority 11-23-16 I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving°authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �b �S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a% QL 34 Hamden Cir Property Address Linda Rowell Owner s Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town 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: System is in good working order with no sign of failure. 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): [sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts =1 Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every. Hyannis MA 02601 11-23-16 - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired.' B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed ppe(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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts la=� Title 5 Official Inspection Form ASubsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 1 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 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: 6 ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i 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 '/Z day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 , Commonwealth of Massachusetts ` .a=1 Title 5 Official Inspection Form f� ' If.;I Subsurface Sewage Disposal System Form Not for Voluntary Assessments a. 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 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. ❑ ® 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 I 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form G. R' I' Subsurface Sewage Disposal System Form Not for Voluntary Assessments . 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16' 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? Z ❑ 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 s Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11-2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? a ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. �W.", Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name f information is + required for every Hyannis MA 02601 11-23-16 page. City/Town I 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ' ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the (/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. . ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts �a=1 Title 5 Official Inspection Fora ' �VI Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments � F 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is Hyannis MA 02601 11-23-16 required for 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): $rr Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts �+ t� Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a% 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name requir at on is required Hyannis MA 02601 11-23-16 required for 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 20" Scum thickness . 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts :a= Title 5 Official Inspection Form I G.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 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): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts �a=1 Title 5 Official Inspection Form ii'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name informati for every on is required Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan):, Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts :a=l Title 5 Official Inspection Form If;., Subsurface Sewage Disposal System Form Not for Voluntary Assessments L_Jfg 34 Hamden Cir _ Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 . 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: 1-60'x2' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system f Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trench in good working order with no sign of back-up into d-box or surrounding stone. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth,of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 P Commonwealth of Massachusetts taa Title 5 Official Inspection Fora r, f ' ,.1,I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection Fora -W-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . . Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A C;? A-3 r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts , � Title 5 Official Inspection Form to=1 (Frs Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 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: 114" 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: You must describe how you established the high ground water elevation: Original design plans show groundwater at 114". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form ! 1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 34 Hamden Cir Property Address Linda Rowell Owner Owner's Name information is required for every Hyannis MA 02601 11-23-16 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commdnvirealth of Massachusetts Title 5 Official-Inspection Form Subsurface Sewage Disposal Systems Form-Not for Voluntary Assessments ' = 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is required for Hyannis MA 02501 5-"7 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this farm.Inspection forms may not be altered in any way. A. General Information 1. Inspector. Shawn Mcelroy Name of Inspector , y Shawn Mcelroy Enterprises Company Name 29 Atwater Dr. Company Address E.Falmouth WA 02536 City/Town State Zip Code 1-508-495-0905 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage•disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of '1~itle 5(310 CMR 15.000).The system: G'J ® Passes Conditionally Passes Q Fail Needs Further Evaluation by the Local Approving Authority 5-9-07 Inspector's Signature Date - to The system inspector shall submit a copy of this inspection report to the Approvi g 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. t5insp•o8/f18 Tfi-5 offer t lnspecbm Fw w StAsutface Savage Daposaf System.Page 1 of 15 . Commonwealth of Massachusetts Title 5 Official inspection-Farm Subsurface Sewage Disposal System Form;Not for Voluntary Assessments �( 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is Hyannis! MA 02601 5-9-07 required for H y every page. CityfTown state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: System is in good working order. ~ 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 a 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 replaces ❑ obstruction is removed t5insp•08108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- , 34 Hamden Cir. , Property Address Linda Rowell L Owner Owner's Name information iredr Hyannis MA 02601 5-9-07 e9 _ every page. Cityfrown State Zip Code Date of Inspection y ,. B. Certification (cunt.) } B) System Conditionally Passes (cunt.): ` ❑ 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 of the environment. ' .4. 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: ❑ t, Cesspool or privy is within,50 feet of a surface water ❑ 'Cesspool or privy is within 50'feetrof 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. ❑ t The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp-OaM Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is H annis MA 02801 5-9-07 required.for y r• every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) -k 4 C) Further Evaluation is Required by the Board of Health (cont:): r.. ❑ 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded r or clogged SAS or cesspool Liquid depth in cesspool is less than 6°below invert or available volume is less El E than 1/2day flow 4 a Required pumping.more than-4 times in the last year NOT due to clogged or ❑ ® obstructed i p pe(s).,Number of times pumped: ❑ ' ® Any portion'of the SAS,cesspool of 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. t5insp•0a/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection- Fo-r { Subsurface Sewage Disposal System Form -Not for Voluntary;Assessments 34 Hamden Cir. Property Address u Linda Rowell ;,- Owner Owner's Name information is required for Hyannis MA 02601 5-9-07 ` 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. ❑ . 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ •-® P Any portion of a cesspool or privy is less than 160 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 coliforrn 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 El '' ® _. '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. t For large systems, you must indicate either'yesn or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ : . 'El: the system is within 400.feet of a surface drinking watersupply ' _j❑ ❑ the system is within'260 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 11 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. t5i�p•08J06 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 y( 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is required for Hyannis, MA 02601 5-9-07 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 ® ❑.. 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? 4 Were,as built plans of the system-obtained and examined? (If they were not . .0 ❑ available note as NIA) ' ® ❑ 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? t ® ❑ ` 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 ® El ' approximation of'distance is unacceptable) [310 CMR 15.302(5)] • / • o- t5insp•08M Title 50fficial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 r Commonwealth of Massachusetts . Title 5 Official Inspection forin Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments. ` c '< 34 Hamden Cir. Property Address _, t•, Linda Rowell !Y i„*•d I Owner Owner's Name information is MA 02601 5-9-07 required for Hyannis' '' a ' every page. Cityrrown State Zip Code Date of Inspection 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 Number of current residents: 2 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: 5-9-07 ' Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow.(based on 310 CMR 15.203): • ,. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No ",,.:`�Non-sanitary waste discharged to the Tdle 5 system? El Yes ❑ No Water meter readings, if available: Last date of occupancy/use: _ ''Date' Other(describe): t5insp•08106 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 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is Hyannis MA 02601 5-9-07 required for y - State Code Date of Inspection City/Town every page. Zip sP D. System Information (cunt.) General Information Pumping Records: .d .. Source of information: Owner—not pumped by in 9 yrs. 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) ' ElTight tank.Attach a copy of the DEP approval. asf ❑ Other(describe): Approximate age of all components,date installed(f known)and source of information: 1996 Were sewage odors detected when arriving at the site? j ❑ Yes ® No t5insp-08= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts An Title 5 Official ,Inspection Fo'rm = Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, x 34 Hamden Cir. , Property Address Linda Rowell + Owner Owner's Name information is ; required for Hyannis MA 02601 5-9-07 . every page. Cityrrown• State Zip Code Date of Inspection D. System Information (cunt.) •.ui'P { Building Sewer(locate on site plan):. N Depth below grade: 16" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet . Comments(on condition of joints,venting,evidence of leakage,.etc.): Septic Tank(locate on site plan):., Depth below grade: 8"feet Material of construction: . ® concrete ❑metal ❑fiberglass ❑ polyethylene t.•. `c ❑ 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: 1000 Gal Sludge depth: 10" •� Distance from top"of sludge to bottom of outlet tee or bafflep •, 16" Scum thickness " Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp•08/06 Tine 5 Offs W Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15- 4 Commonwealth of Massachusetts ug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is required for Hyannis MA 02601 5-9-07 every page.. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommended pumpeing for solids. 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: w 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): t5insp•08= Title 5 Official inspection Forth:Subsufiace Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Forrn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir. Property Address w Linda Rowell . Owner Owner's Name information is required for Hyannis _ MA 02601 5-9-07., every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Y} Tight or Holding Tank (cunt.) : . r , Dimensions: Capacity: gallons Design Flow: _ , gallons per day— Alarm Alarm present: ❑ ,Yes El 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.): Good condition. Pump Chamber(locate'on siteplan): ` Pumps in working order: ❑ Yes_ _ ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08M Title 5 Official Inspection Form:Subsurface Sewage Disposal g posa System•Page 11 of 15 Commonwealth of Massachusetts - Title 5 Official InspectionForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is required for Hyannis MA 02601 5-9-07 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: a ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number;length: 1-60'x2' ❑ leaching fields number,dimensions: '❑ overflow cesspool number: - ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,,damp soil, condition of vegetation, etc.): No sign'of back-up or break-out. - t5insp•08/06 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is required for Hyannis MA 02601 5-9-07 every page. Cityrrown r State Zip Code Date of Inspection D. System Information (cunt.) 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.): t5insp-08= Title 5 official trispection Forth:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts ` w Title 5 O dial Ini ection Fotm , . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name hforrequired is Hyannis MA 02601 5-8-07 required for Y every page. City/Town State Zip Code Date of frspection 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. >/ L 36, t5insp-08M Tide 5 OfrictW(nspechon Form:Subsurface Sewage Disposal System•Page 14 of 15 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Hamden Cir. Property Address Linda Rowell Owner Owner's Name information is required for Hyannis MA 02601 5-9-07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ 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: You must describe how you established the high ground water elevation: Records on file show water at 6'. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS 6 y EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTECTI ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 �r TRUDY COXE WILLIAM F. WELD Secretary Governor ARGEO PAUL CELLUCCI DAVLD B. STRUH r Lt. Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI N FORM PART A �j CERTIFICATION t \ Address of Owner C. :�� `��`�q�1►' Property Address: 3y ►'^^��t� `�-1 Date of Inspection: (If different) Name of Inspector: Cir.r ,e-\ CN I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: T 1 2 ML- Mailing Address: i-i ce F,. . r t M C)Z.loy Telephone Number: 1;C-,7,—y`'ll 1 �7 _cI 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: Bate' O 2` The"System Inspector shall submit a copy of this inspection report to the Approving Authority within chitty (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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUNDLARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CNiR 15.303. 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exflltration. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: 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 bro4n�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). Describe observations: 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 obs cted pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HE TH: Conditions exist which require further evaluation by the Board of 'ealth 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 HEALT DETER%NIINES THAT THE SYSTEM IS NOT FUNCTIONING IN A . MANNER WHJCH WILL PROTECT THE PUBLI ALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a rface water Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BO OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER,tiIINES THAT THE SYSTEM FUNCTIONLNG IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONbIE _ The system has a septic nk and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface ater supply. _ The system has a se tic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a eptic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system ha a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply ell, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from ollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method sed to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) P2ge 2 of 10 a: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property AddrEss: . Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate either "Yes" or 'No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined n 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine at will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or ogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface ters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availabl volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT a to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool o privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fe of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a ne I of a public well. Any portion of a cesspool or privy is within 0 feet of a private water supply well. Any portion of a cesspool or privy is les than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If t well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic co pounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each f the following: The following criteria apply to large sy ems in addition to the criteria above: The system serves a facility with a sign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environm nt because one or more of the following conditions exist:. Yes No the system is withi 400 feet of a surface drinking water supply the system is wi in 200 feet of a tributary to a surface drinking water supply the system is ated 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 i requirements of 314 CNIR 5 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3kk *n v\.cLW Owner: W1O'Q Date of Inspection: �`a\C' Check if the following have been done: You must indicate either 'Yes' or "No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components. excluding the Soil Absorption.System. have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or —k tees, naterial of construction, dimensions, depth of liquid, depth of sludge. depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM UgFORIMATION Property Address: Owner: Date of Inspection: M`�L ` FLOW CONDITIONS RESIDENTIAL: Design flow: 'D., U0 .p.d./bedroom for S.A.S. Number of bedrooms: 0 -, Number of current residents:UZ Garbage grinder (yes or no):_J Laundry connected to system (yes or no):—�t Seasonal use (yes or no): t-� Water meter readings. if available (last two (2) year usage (gpd): Sump Pump (yes or no):� Last date of occupancy:_Dn2&2tJ CONLNIERCIAL/T DUSTRIAL: Type of establishment. Design flow: eallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readines. if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INTOMATION PUNEMG RECORDS and source of information: * am QS QnaoVL - Svstem pumped as part of inspection: (yes or no)_t-0 If yes. volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: k u19_ t Sewage odors detected when arriving at the site: (yes or no) p2oe 5 of 10 ' 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION. (continued) !Property Address: 3 y 4R't)✓� tN Owner: k .w Date of Inspection:11aI�\4� t BUILDING SEWER: 1 (Locate on site plan) /va Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints. venting, evidence of leakage, etc.) i SEPTIC TAINK:Nh (locate on site plan)' S H Depth below grade: Material of construction: ?1concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list are _ Is age confirmed by Certificate of Compliance _(Yes/No) .Dimensions: k00C> Sludge depth: 0 tk' Distance from top of sludV.e to bottom of outlet tee or baffle: Scum thickness: n't Distance from top of scum to top of outlet tee or baffle: b� Distance from bottom of scum to bottom of outlet tee or baffle: 1 �t How dimensions were determined: Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, strActural in(egr evidence of leakaee. etc.) C N C tJ0 GREASE TRAP: �d (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri(y. evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: t1c- Date of Inspection: tV 17A`Cru TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in workinc order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) ►ISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_?,B-Q& Wlo a Comments: note if level and distributions a%ai�l, c%idence of solids carryover, evt nce of leakage into or o t of box, etc.)_ CCX!d_ PUMP CHAMBER:{) (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) f - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: KC,(si�� nl Date of Inspection: 161z(q� SOIL ABSORPTION SYSTEM (SAS):�g (locate on site plan, if possible: excavation t required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches. number.length: 1 leaching fields. number, dimensions: overflow cesspool. number: Alternative system: Name of Technology: Comments: (note condition of soil. signs of hydraulic failure, level of ponding, co didon of eg on, etc.) t N Wi Ln CESSPOOLS: (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 (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) baterials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04125197) Page I of 14 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR NI PART C SYSTEM INFORMATION (continued) Property Address: 3� b�Vl `�atti1 Owner: µC i �w Date of Inspection: - SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ( aA • ItZ- 33 t � � (revised(d:25 97) P-age 9 of 10 y i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOPUNI PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:mt av4co Depth to Groundwater 5 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in your own words how you established the Hich Groundwater Elevation. Must be completed) (revised 04/25197) Page 10 of 10 t ,: TOWN OF BARNSTABLE `I.66TION 3LI SEWAGE # f VILLAGE *eN t.S ASSESSOR'S MAP & LOT 22 4 I VS INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY WOO q`R LEACHING FACILITY: (type) aUk�04-', (size) ® 1 NO.OF BEDROOMS BUILDER OR OWNEER �.LAu Q�n�,Lvy , SATE: Lb 12.��l COMPLIANCE DATE: Separation Distance Between the: c Maximum Adjusted Groundwater Table to the 5 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) IA Feet Edge of Wetland and Leaching Facility(If any wetlands exist. i within 300 feet of leaching facility) NI �' Feet Furnished by �2 C.LL-t7 _ ('� (1 �� �' N• � C1J „ .. � � � � � o � ► � � �P� -, s � � � � � 1 w �' 6_ a, .. �, TOWN OF BARNSTABLE LOCATION �y /� �e� ��� SEWAGE # % —^ ,V� Y VILLAGE �s/�nns,s ASSESSOR'S MAP& LOT• Z-1e-< INSTALLER'S NAME&PHONE NO: SEPTIC TANK CAPACITY LEACHING FACII.PTY: (type) J 7-rg04eA (size) XJe NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: ^' � � Separation Distance Between the: ` Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa lity) Feet Furnished by A'Aar" e it o � - -�f l r � No. Fee�, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplicatiou for Miqual *pgtem Cougtrurtiou Perron Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. : � «i l k'✓� .4 i Type of Building: ..� Dwelling No.of Bedrooms ..S Garbage Grinder( ) Other Type of Building g No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7—eig .-ic-A Date last inspected: Agreement: The undersigned agrees to nsure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provis'ons f;Title the Envgo ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been s is and f He Signed Date Application Approved by 3e Application Disapproved for thkollowingk1easons Permit No. 91 — ; ��� Date Issued f .... .-_. ,;... k;{•..y•a. a..� V �-.:+pro.•. � � / +' / d V ��-.�a.r •� � — No. L ! Fee THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migpool *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. y //Am ct e C/2 �'I72 �,/�2.P0 e7 Installer's Name,Address,and Tel.No Designer's Name,Address and Tel.No. i'►'/t A cApe Sept►c Cons F L(I Type of Building: N Dwelling No.of Bedrooms 3 Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) 3 Other Fixtures 1 Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title s Description of Soil i Nature of Repairs or Alterations(Answer when applicable) - Sou O X a x •7�,�QnC,<i i Date last inspected: r Agreement: The undersigned agrees t nsure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions f Title the Enviro ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been s e by t is and f He t . Signed Date": ` ' %I ` l Application Approved by4-3 I! i Application Disapproved for th followin easons Permit No. — Date Issued t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-s' a Sewage Disposal System installe ( )or repairedkeplaced( )onx_ by •of f+ for as leg has been construct d 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: i I No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS j lwigogar *pgtem Construction Permit Permission is hereby granted to n,J 2t� to construct(. )repair(kan On-site Sel6ge System located at r 3 y �`c�eti CirL 11yAn n c x� 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: r/'-i Approved by ,.2. r CERTIFICATION OF SKETCH AND APPLY WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLAN ) VS I e9 UH° 1�-y , hereby taertify that the epp c tio�for dit w ` s construction permit signed by me dated` 4' property located at 'd /�.9 rrP c�p 0/i �/2 • � �'��e...y`�tf���lE���I Ul0 :.a: . following criteria. six }i. / t�. � ed`�i{�k����t'�.•��iy t'�:6'/`�`'$ hTTA"`° P'tik°� s3E,' 2''�L�t � rb'�,'. r�i�rtit�u„�'A'T • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system ` � ,,.<� •fit=,> The observed groundwater table is 14 feet or greater below the bottom of flre leslcihih�it 1 j ; a There is no increase in flow and/or change in use proposed Y • There are no variances requested or needed. a sr ;}arc' c a Fetes" ." SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN HE TOVIN OF n��Anf.� [Attach a sketch plan of the proposed system. Also if the licensed installer posesses g this plan should be submitted]. . t�.z .�Yp;xN ii4.t r�s :pt ttt+ .q 1 tt #s *'1gf S�✓4 gl� d � i SN f .. x .rt�x�+tm . _ ���=`5�j R's'zt•i�'ra ��uP�`w SC��'tX E,.!`.Y�' .� R�. �.� �i�a�`�4`�s}7` 'C4+ iyt'1: r f 7 i 03 u f LOCATI N SEWAGE PERMI � N V I I` L A D E HNC INSTA LLER'S NAME i ADDRESS y B UIIDE R OR OWNER DATE . PERMIT ISSUED DAT E COMP-LIANCE . ISSUED a � o a � o -64 Fms.....% ................. THE COMMONWEALTH OF MASSACHUSETTS A BOAR® O HEALT / ......OF......... ....... ....... ....:. ... ..... / Appliration for llhipwi al Works Tnnitrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair. ( ) an Individual Sewage Disposal Sy' stem at Location- ess �— or Lot No. - ..: .. .. ------------- -_f������--------•------------- "ner M ! Address a -- -- ............ - ----------------------- Installer Address Type f Building Size Lot� __�= _ --Sq. feet U Dwelling—No. of Bedrooms._..........3-_•-_.-..___ _---Expansion Attic ( ) Garbage Grinder ( ) No. of ersons.._._.,�_-•--------------- Showers — Cafeteria pa., Other—Type of Building .................. p ( ) ( ) < Other fixtur ......... W Design Flow______________ ___ __ -__ _ gallons per person e�day. Total daily�flow.._........_.__�. __.. .......................... -- ------- --- WSeptic Tank—Liquid capacity-/ gallons a Length__ ___________ Width.... Diameter................ Depth................ x Disposal Trench—No. _-___ _.._.__..._ Widt Total Length..___...._._._.__ Total leaching area....................sq. ft. Seepage Pit N Diameter---Diameter.___ _..�._ Depth below inlet._6.�.�... Total leaching area.__- ____ q. Z Other Distribution box ( }- 9dsin'tank ( ) ft. aPercolation Test Results Performed by------- .... Date... to ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_ . ..__._. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..___.____ _....�� a --••••... 1 -------- i..__..._.... Description of Soil--•--- s . ---------- ------...- a �r� x :. •---------- ..................... _ __ .__....__ _ _____ -..6. W - -= -� . . =---------------•- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------•___.____-____-----_-__________-______-_---------•.---•__. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions.of TTT12 5 of the State Sanitary Code— The undersigned further agrees of to place the system in operation until a Certificate of Compliance has been issued by the board of h -th. s Sigd. . _._ ......................... o� Date Application Approved By........ t� !J r v�` � -------- Application ate Disapproved for the following reasons-------------------------------------------------------------................................................. ---------------------------•-•-------•-----------------------.........---------------.......--------...--•----------•-•-----•-••-----•••-•--•--•--•--•-•-------•--------•--•••----------••••-•••..-•---- y Date '�^ 2 c� PermitNo......................................................... Issued_--•----•--•----•--•-------•--� ............ Date No............. .. FE$ ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF � EALTH -- O F.........................:°............--------------------.._............................ Appliration for Elispati al Works Tonstrnrtilan rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .............. Al z' `. 'f__ 2A� X:&a Location-Add-ress or Lot No f Owner f Address .fi .... ....... � rt2? s'* ........................ Installer Address dType of Building Size Lot-r___ ___ ____ ___ ___ Sq. feet V Dwelling No. of Bedrooms...... x ansion Attic Garbage Grinder g— P ( ) g ( ) Other—Type of Building ............................ No. of persons...... ------------------ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------•---- . w Design Flow.............. .. gallons per person er day. Total daily flow............... C4 Septic Tank ' Liquid capacity/gallons P Length-_ .'�.._.. Width_.. S. ._. Diameter................ Depth................ Disposal Trench—No. :___.__ Widths: . _._... Total Length..........i.- Total leaching area....................sq. ft. Seepage Pit No....../............ Diameter... izsingOtank... Depth below inlet..._ __.____ Total leaching area. '7:_sq. ft. Z Other Distribution box ( ( ) r Percolation Test Results Performed by........ f ......� Date... .................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___._-....-•---.._.__. f/ f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._ .__._ t� 1 1 •- ••............. ` . O Descriptio of Soil-------•- y ;;:.: "...... '' ' .- .... .. .1 ._ U •-•.........-- ..-- . .. . = - UNature of Repairs or Alterations—Answer whe applicable-----:......................................................................................... Agreement: The undersigned agrees to install the aforedescribed: Individual Sewage.-Disposal System in accordance with the provisions of TIT 12 5 of the State Sanitary 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. h - Sig d . Date Application Approved BY--...-- •- G1 � __ - "W__"'_ 'Wit,Application Disapproved.for the following reasons----------------•------•----...... ...................••-•-----------------•-•-•------•--------•---.................------------------------------------------------------------------------------------------------------------------------- Permit No........................................................ Issued_................................. ..........Date.......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH IQ (9prtifiratr of Toutplianrr THI IS TO CERTIFY That the Ind Widual S wa e Disposal System constructed or Repaired Installer -----------•--------••-------------------------- n has been installed in accordance with the provisions of T r F 5 of The State Sanitary C e s described in the �. application for Disposal Works Construction Permit No. ........._ _______________________ dated_..' l .7 .'_.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT-THE SYSTEM WILL FUNCTION SATISFACTORY. - ; DATE----- ..1_..7.94r..........................=•--•-•---- Inspector.......... •- t--------------------•----•----•-...____--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N .... G 7 ..... FEE. ....--•--.......... Dispnoat Mor m Tad; :�trnrtilan print# Permission is hereby granted...... .�`_-_ a' _., _' ._.; __:__- __. 1 to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo........................................................................................................ ............................................... Street � as shown on the application for Disposal Works Construction P it o. _._; , _______ Dated._ �r ...�lF.:'_�..�!_7 ' ` Board of Healt DATE..... �� FORM 1255 HOSES & WARREN, INC., PUBLISHERS TOWN OF BARNSTABLE ` 3q �/ LOCATION 1 L 4 Put. <1 SEWAGE # VII,LAGE /T�/��� s ASSESSOR'S MAP& LOTo2f/' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1006 / // // LEACHING FACILITY: (type) Lenc4 4rev�4 (size) OHO NO.OF BEDROOMS 3 / p / BUILDER OR OWNER L in If ow,e`� PERMITDATE: COMPLIANCE DATE: Separation Distance'Beivveen the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility jt Feet Private Water Supply Well and Leaching Facility (If any wells exist F, on site or within 200 feet of leaching facility) , Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o leaching facility) 11 Feet Furnished by Jl ��✓✓r /u f�lr,7-t> SPATGr T�tS, J b r1 LA et -O 4 i 2 a z WN OF EA NSTA�BLE OCA,,'A'ION �t'`•v` SCWAG� Vi' L OS INSTALLER'S NA I�M&P (?IdE NO ISEMC TO CA,PACITY LFsAtCI I►tG:pl�C1II:1 ryi (ta) l re 3` Sepn><atlo�t�istaa«�Betv�aeta c&O.-OFUDROOM Ile" DATE Msxi n um }uStdcJ G►autadwatev'Calite to t(tc Hattom of Leschin�k�ac oty. . - . fee 11vc;Wnt6r,5aljr '1Ga1.Astiei{�eaciteg pAcriaty �►yiQ19s exist pry ei�a ac;wltli�n fool 2AO �t of Nutuftg .Ell uty) Fctuc cif i1V0-di adid I:eacuto9fi stley.(lf Any wetlands exise _ riithtu 3t30 feet. ieaCl�itig tuciiity . ,1 � ,� ��—��'""""..'_;" Q�O) _ W IS'S. VI ..�'�4"W / ) FIIY+�H G'>QA D�•l!?�,�'Q � F"i N 4SF� rs1R'Ati+'� F f Aitt'fl �rf't A DLL` "-'--•^----� 7.7777 IA T4P C f F-dVNP. t/eV�t'�t1r, r�a,-�/JC�j ��`s�3�C�'ie�c��•�K�[��v�ln.�'�;?.vr��W:-� tom. WdLL IN 4 3 t,-O 4 sr.*w4f o o d t 6Et.t_A R i:"4. � •, f dD0- elr.�l�t• ,` ��_ � � / d o 0 0 0 0 �� � i 3�4 a � 1 t t,N sy �r D tT. 6c x > f h�tNl a CowG• I / \0 o o O o O i "W"PSIVeCP S-YWAOW SEPT!C 'TA/V K•r----_--�"'T"_..__---To GE �.EYfL � a a y ! G`o fLEv = Z x /V!r PST ra- QF .rsp�ao � : 3 $oTTon%t 50 �c c = �o �T # 2Z 1 4rlt To-r A.+_ = 45� �• lees': o y-fs+' 0 s 7s s - .. 5 r 21 vrcr rE,r��H% Rnr SAND >z�sr t l►..IE - . 75 « _ : (DR,Os"a 9•S�fr btu 4C'e 0/�.S, S'AG YSTFs I /.vS 'EG rEp ,ray : �'��- MuZ�=�'y ` 80. t-� .-rta /�'rPDf OSG�17 �i�YEG L/NG '.-1 o ff, , �g-�1 �? STA ,t /t4.1o.1 N 1�� MASS. 'Ap,r'.cr. 10"7� .r: < Z M IQ KI c M se A�E: � �o � P09 re., 5, Of 'to aF , Cam. Ac.,QrS ' Ay..-ry elotr No cRas . ;4 it/o,PMA/V !rRaS 'MAN R E s' © A 224a A1,044y PD/rlrr RV . �+�,c� �tiy'``rr' .,�.� � ,.M' GE'JV'T'�JF' V�LLE.. SASS• WK � y