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HomeMy WebLinkAbout0208 OLD YARMOUTH ROAD - Health 208 OLD YARMOUTH RD, HYANNIS A= i o I • Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments — a IF Old Yarmouth Rd. Hyannis, MA 02601 Property Address Cape Cod Brokerage Owner Owner's Name requir atlfore Orleans MA 02653 2/17/11 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms. A. General Information on the computer, use only the tab " 1. Inspector: key to move your cursor-do not Paul C. Martin use the return key. Name of Inspector BLUEWATER HLD CORP r� Company Name Ada . 350 MAIN ST-ROUTE 28 = 4- Company Address 'j WZ1 W YARMOUTH MA 02673 -�a City/Town State ` Zip Codef 800=593-6449 ` 5016 m " 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: ❑x . Passes El Conditionally ❑ Fails - Passes ```oatll,III ElNeeds Further Evaluation by the Local Approving Authority`�.�`�y�k�;�:•• OF -Ssgc4�� .• PAUL aN= C. cam= o U. MARTIN :y 2/17/11 3�r• c Inspector's Signature Date O The system inspector shall submit a copy of this inspection report to the oard of Health or DEP)within 30 days of completing this inspection. If the system is a s 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 09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System,-Page 1 of 16 Commonwealth of Massachusetts 4 F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s iG H Owner B. Certification (cont.) information is required for every Inspection Summary: Check A,B,C,D or E/always complete all of Section D pane. A) System Passes: 0 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 appears to be in good working condition. B). System Conditionally Passes: El 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): B. Certification (cont.) t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments B) System Conditionally Passes (cont.): Owner ❑ Observation of sewage backup or break out or high static water level in the information is distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution required for every box. System will pass inspection if(with approval of Board of Health): page. ❑ 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 B. Certification (cont.) t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 3 of 16 Commonwealth of Massachusetts r Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 c,M 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 ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is Owner 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 Tess 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 ❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due town 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 ❑ 0 .Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow B. Certification(cont.) Yes No ElRequired pumping more than 4 times.in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:. ❑ ❑x Any portion of the SAS,cesspool or privy is below high ground water elevation. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 16 h Commonwealth of Massachusetts I r-4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S ,M ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Owner ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. information is required for every ❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. page. ❑ ❑x 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.] El M The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 0 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. C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ x❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? x❑ ❑ 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? t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 16 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Owner FZ ❑ Was the facility or dwelling inspected for signs of sewage back up? information is required for every x❑ ❑ Was the site inspected for signs of break out? pave. x❑ ❑ Were all system components, including the SAS, located on site? D ❑ 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'_ ❑x ❑ 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: ❑x ❑ Existing information. For example, a plan at the Board of Health. R ❑ 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): Number of bedrooms (actual): DESIGN flow,based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): D. System Information` Description: Number of current residents: Does residence have a garbage grinder? ❑Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑Yes ❑ No Laundry system inspected? ❑Yes ❑ No Seasonal use? ❑Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Water meter readings, if available (last.2 years usage (gpd)): Detail: Owner information is required for every pa4e. Sump pump? []Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Warehouse Type of Establishment: gpd g 300 g Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 300 gpd Grease trap present? ❑Yes Z No Industrial waste holding tank present? ❑Yes Z No Non-sanitary waste discharged to the Title'5 system? ❑Yes Z No. Water meter readings, if available: N/A D. System Information (cont.) Last date of occupancy/use: 2/17/11 Date Other(describe below): General Information Pumping Records: Source of information: No Records on file Was system pumped as part of the inspection? ❑Yes No If yes, volume pumped: gallons . t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 . Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M How was quantity pumped determined? Owner Reason for pumping: information is required for every Type of System: paAe. ❑ 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): -Septic Tank and Single Leach Pit. No D-Box present. D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 per previous plan on file at BOH: Were sewage odors detected when arriving at the site? ❑Yes ❑X No Building Sewer(locate on site plan): Depth below grade: fe e et 1 t Material of construction: X❑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.): Minor scaling of cast iron. Joints appear secure and properly pitched. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 16 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Septic Tank(locate on site plan): 91. Owner Depth below grade: feet information is required for every Material of construction: va-qe. x❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1000 Gal H-20 Precast 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. 8" Sludge depth: D. System Information (cont.) Septic Tank(cont.) Distance from.top of sludge to bottom of outlet tee or baffle 2211 . Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Sludge Judge, 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.): Recommend maintenance pumping on tank. Fairly heavy sludge and scum building up. Grease Trap(locate on site plan): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Depth below grade: feet Owner Material of construction: information is required for every ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): page. 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 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_ El No ' Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Comments (condition of alarm and float switches, etc.): Owner information is required for every page. *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) 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.): 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16 Commonwealth of Massachusetts r Title 5 Official Inspection Fora - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Soil Absorption System (SAS) (locate on site plan, excavation not required): Owner If SAS not located, explain why: information is required for every pa4e. D. System Information (cont.) Type: ❑x . leaching pits number: 1-6x6 H-10 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number 2 - ❑ 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.): 16" of standing water in pit. No staining above current water level. Minimal solid carry over. No signs of hydraulic failure. Cesspools,(cesspool must be.pumped as part of inspection) (locate on site plan): Number and configuration Depth=top of liquid to inlet invert t5ins•09/08 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Depth of solids layer Owner Depth of scum layer information is required for every Dimensions of cesspool Pape. . Materials of construction Indication of groundwater inflow ❑Yes ❑ No 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.): D. System Information (cont.) t5ins•09/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 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: Owner information is ❑ hand-sketch in the area below required for every drawing attached separately page. D. System Information (cont.) Site Exam: Check Slope NONE Surface water NONE t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;u x❑ Check cellar N/A Owner Shallow wells NONE information is More than 15' required for every Estimated depth to high ground water: page. 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 groundwater elevation: Previous inspection noted 15'test hole on file. Date of test hole was not noted. Bottom of Leach Pit is 8;8„ Before filing this Inspection Report, please see Report Completeness Checklist on next page. E.- Report Completeness Checklist ❑x Inspection Summary:A, B, C, D., or E checked F Inspection Summary D (System Failure Criteria Applicable to All Systems) completed 0 System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 COMMONWEALTH OF MASSACHUSETTS ¢, r Title 5 Official Inspection Form a y� Not for Voluntary Assessments Subsurface Sewage Disposal System form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 Cityfrown State Zip Code_ CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 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. FNN iD or ck 0 f l { COMMONWEALTH OF MASSACHUSETTS 0 Title 5 official Inspection Form . Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Property Information: MAP 344—PARC 080p? 208 OLD YARMOUTH ROAD — HYANNIS, MA 02601 Property Address CAPE COD HOSPITAL Owner's Name 208 OLD YARMOUTH ROAD Owner's Address HYANNIS MA 02601 City/Town State Zip Code FEBRUARY 26, 2007 Date 2. Inspector: ta�.. JAMES D. SEARS -' Name of Inspector , A & B CANCO Company Name 350 MAIN STREET ^�j -.- Company Address WEST YARMOUTH MA 02673 � City/Town State Zip Code I 508-775-2800 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The System: ® Passes ® Conditionally Passes ® Fails ® N�urtherEvaluation =LIAoving Authority 3 _C Ih or'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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form n � Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 208 OLD YARMOUTH ROAD Owner's Address HYAN N IS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 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: B) System Conditionally Passes: N/A ❑ 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 I COMMONWEALTH OF MASSACHUSETTS N w Title 5 Official Inspection Form 0�r Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 208 OLD YARMOUTH ROAD Owner's Address HYANNIS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection B) System Conditionally Passes (cont.): N/A 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: 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: N/A ® 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS w W Title 5 Official Inspection Form Not for Voluntary Assessments Vey`WW Subsurface Sewage Disposal System Form B. Certification (cont.) 208 OLD YARMOUTH ROAD Owner's Address HYAN N I S MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection C) Further evaluation is required by the Board of Health (cont.): N/A €: 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 that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 COMMONWEALTH OF MASSACHUSETTS N W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 208 OLD YARMOUTH ROAD Owner's Address HYAN N IS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A 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 pit is less than 6" below invert or available volume is less than '/2 day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® ® Any portion of the SAS, cesspool or privy is below high ground surface water elevation. ® N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® N/A Any portion of a cesspool or privy is within a Zone 1-of a public well. ® r N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® r N/A 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.] YES No ® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd. 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 COMMONWEALTH OF MASSACHUSETTS N Title 5 Official Inspection Form a s' Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 208 OLD YARMOUTH ROAD Property Address HYANNIS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection E) N/A-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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 N COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 208 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 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, including 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments s�• Subsurface Sewage Disposal System Form D. System Information 208 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection Residential Flow Conditions: N/A Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? Yes ® No Is laundry on a separate sewage system?[if yes separate inspection is 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: Commercial/Industrial Flow Conditions: ✓ Type of Establishment: WAREHOUSE Design flow(based on 310 CMR 15.203): 300 GPD Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.) 300 GPD 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: N/A Last date of occupancy/use: PRESENT Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection 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,.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: 1983 Were sewage odors detected when arriving at the site? ® Yes F71 No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments. Subsurface Sewage Disposal System Form D. System Information (cont.) FEBRUARY 26, 2007 Property Address HYAN N IS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection Building Sewer(locate on site plan): ✓ Depth below grade: 12" 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.): CAST IRON INLET TEE. Septic Tank (locate on site plan): ✓ Depth below grade: 9" 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-GALLON PRE CAST H-20 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" 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 18" How were dimensions determined? PLAN &TAPE Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 f -� COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form 9 • O Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 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.): TANK AT WORKING LEVEL, H-20 PRECAST. TANK AT 9" BELOW GRADE WITH STEEL COVER ON INLET. OUTLET COVER SHOULD BE RAISED. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: ® concrete Elmetal 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): N/A Depth below grade: Material of construction: ® concrete ® metal ® fiberglass ® polyethylene ® other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page I l of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection Tight or Holding Tank (cont.) N/A 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 a copy of current pumping contract(required). Is copy attached? ® Yes ® No Distribution Box (if present must be opened) (locate on site plan): N/A 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.): Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes ® No Alarms in working order: ® Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 f -� COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments s Subsurface Sewage Disposal System Form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): ✓ Soil Absorption System (SAS) (locate on site plan, excavation not required):,( If SAS not located, explain why: Type: leaching pits number: 1 leaching chambers number: leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number: ® innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)-. LEACHING IS ONE 1000-GALLON PRE CAST PIT. PIT & COVER AT 32", PIT WET, STAIN LINE AT 8". NO SIGN OF OVER LOADING OR SOLID CARRY OVER. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form m 0 Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYANNIS MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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, damp soil, condition of vegetation, etc.)-. Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)-. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 -� COMMONWEALTH OF MASSACHUSETTS� " Title 5fOfficial Inspection Form °K. Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N IS MA 02601 Cityfrown State Zip Code_ CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 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. RaA"� Al iD c d< 13)-#ck '7a P -� COMMONWEALTH OF MASSACHUSETTS W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 208 OLD YARMOUTH ROAD Property Address HYAN N I S MA 02601 City/Town State Zip Code CAPE COD HOSPITAL Owner's Name FEBRUARY 26, 2007 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to NO ground water: 15 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: TEST HOLE ON SITE PLAN 15 NO GROUND WATER. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 ,�-- z € G/ ,/ � � cj�I/y�e n'` yDLc.`'' �f l �.� ��nn � ' { y �I� � ° �� I � � isa 1 - .��'�� `, °� �� YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Main Street, Hyannis, MA 02601 (Town Hall Town Clerk's Office, 1°`FL.,`367 C r I2" � , f � q DATE: Fill in lease: Ors APPLICANT'S YOUR NAME/5: p ¢ gaI oV BUSINESS ` �c �2 5M YOUR HOME ADDRESS: S T { � TELEPHONE # Ho me Telephone Number NAME OF CORPORATION: 5 NAME OF NEW.BUSINESS ` TYPE OF.BUSINESS 2.1 IS THIS,A HOME OCCUPATION? YES NO: ADDRESS OF BUSINESS S An _ a MAP/PARCEL;NUMBER . 0 , - ©e( [Assessing)., When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstdble. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally-opera te your business in this town. 1. BUILDING COMMISSIONER'S FIC This individual has 1 rmed f ny permit requirements that pertain to this type of business. o i d Signature* COMMENTS: 2. BOARD OF HEALTH _ This individual has b informed oft rmit re i�ements that pertain to this type of business. MUST COWLY WITH ALL ut orized Signature * COMMENTS: "AZARDOW MATERIAL$REGULATIONS _ 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business.' Authorized Signature** COMMENTS- aza Date - +hysical Street Address-Check database to ensure it exists Working Phone Number /Actual Amounts -( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials-no blanks) Storage Information -location of storage, how long is storage for? If none., note that. Disposal Information :where and who? If none, note that. G �GApplicant Signature - understand what is listed and noted -- 'V Staff Initial -.any questions, know who to ask hicle Washing/Rinsing? .-give a vehicle washing policy and explain it Attach the Business Certificate with your sign off.and comments "The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to'explain what you discussed with them. Date: / p / dos D l 6 1 TOWN OF BARNSTABLe /g 3 TOXIC AND HAZARDOUS MATERIALS ON-SIT INVENTORY NAME OF BUSINESS: ` BUSINESS LOCATION: INVENTORY MAILING ADDRESS: 6 o S Loc,,.-A S t rl..'_� e.` wy 1 I -70 TOTAL AMOUNT:- TELEPHONE NUMBER: S(( ' s " 40 v d4- -� CONTACT PEON: 12ct 5SL 0 la^A1Z uCKn,/1 f 6U0 �p. � �1 EMERGENCY CONTACT TELEPHONE NUMBER: jo to # MSDS ON SITE- � TYPE OF BUSINESS: l I r1S INFORMATION/RECOMME DATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides VNEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED (� Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) - NEW- • USED— Any other products with "poison"'labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes m y be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS • • : ' ' : • • : • ' �� satisfactory 2. •rinters . Shops3.Auto Body see"Orders") 6.Fuel Suppliers 7.Miscellaneous C:�se lots Drums Aboye:Tznks= Underground Tanks fin=- i • 1 , 1 rA All f y� r 1 • 1 1 • Nommi e WNW I, TIMIMM" "INUIVal. .... �� ✓ f LLB s.,,i �1. � rJ/l�� I 1, Name of Hauler Destination Waste Product Licensed? r�I / AM III TOWN OF BARNSTABLE OMPLIANCE: CLASS: 1.Marine,Gas Stations,Retai satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY �.;� (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS �' ' Class: 7.Miscellaneous �' -•� �� TITIES AND STORAGE (IN= indoors; OUT=outdoors) MAJOR MAT `[ ground IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel(A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers M=eous: 41.41 N �r;1r DISPOSAURECLAMATION REMARKS: Ila=L 1. Sanitary Sewage 2. ater Supplyi'` Town Sewer Public A O On-site 8 Private 3. Indoor Floor Drains YES N0� O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES NO ORDERS: Q Holding tank:MDC 4Catch basin/Dry well 0n-site system 5.Waste Transporter Narne of Hauler Destination Waste Product YES NO 2. 7?n2 P son (s) Interviewed Ins ctor Date a�j Q TOWN OF BARNSTABLE LOCATION �`f /® U © /�� �y SEWAGE # 'VILLAGE /r y ASSESSOR'S MAP & LOT 3�7 ` ®�o i �S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS / BUILDER OR.OWNER l s,�d PERMITDATE: DATE: U " d Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a c !� o -1 00 o 1 J r ti C