Loading...
HomeMy WebLinkAbout0033 PINE LANE - Health 33 Pine Lane Osterville P A = 118 088 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pine Lane Property Address r~+ Adrienne Cozzolino Owner Owner's Name _ information is required for every Osterville MA 02655 October 11, 2016 06page. Cityfrown 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 9, 2 L on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating �y Company Name P.O. Box 89 Company Address ` Forestdale MA 02644 Cityfrown State Zip Code 508-888-6055 S112843 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 115.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 14, 2016 Inspectors 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 Insoection Form:Subsurface Sewage Disposal System•Page 1 of 17 400161 V-) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is Osterville MA 02655 October 11, 2016 required for every 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: 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" QY, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years d* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration o exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace with a complying septic tank as approved by the Board of Health. A metal septic:tank will pass insp tion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the'tan is less than 20 years old is available. ❑ Y ❑ N ❑ D (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 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 pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of B rd of Health): ❑ broken pipe(s) are;replac ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is I eled 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 J ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed /'. ❑ Y ❑ N, ❑ ND (Explain below): C) Further Evaluation is Req red by the Board of Health: ❑ Conditions exist which re ire further evaluation by the Board of Health in order to determine if the system is failing to p tect public health, safety or the environment. 1. System will pass nless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that th 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 Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 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 abso/pp'tion 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 SA *and the SAS is less than 100 feet but 50 feet or more from a private water supply we . Method used to determine distance **This system passes if the well w er analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t t no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Ili 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 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 - page. City/Town State Zip Code Date of Inspection B. Certification (cant.) 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 equal to or less than 5 m . of ammonia nitrogen and nitrate nitrogen is q pP , 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- 9P 10 000 d. ❑ ® The system fails. ► 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 to115,000 gpd. For large systems, you must indicate either" es" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is (thin 400 feet of a surface drinking water supply ❑ ❑ the system within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area— I PA)or a mapped Zone II of a public water supply well If you have answered "yes" t any question in Section E the system is considered a significant threat, or answered "yes" in Sectio D above the large system has failed. The owner or operator of any large system considered a signi cant 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 Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is Osterville MA 02655 October 11, 2016 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® -❑ Pumping in, 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? ® El available 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 450 GPD* t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 page. Citylrown State Zip Code Date of Inspection D. System Information, Description: "Based on 6'x6' pit w/ 1 5' of stone in soils <2 min per inch. 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2• ears usage d 2015= 120 GPD" 9 ( Y 9 (gP ))• 2016= 182 GPD' Detail: "Property has seen very light usage over past couple of years. Water use durring summer use includes irrigation. Sump pump? ❑ Yes ® No January 2016 Last date of occupancy: Date Commercial/industrial"Flow Conditions: Type of Establishment: I Design flow based on 310 CMR 15.203 : / g ( � ) � Gallons per day(gpd) Basis of design flow (seats/persons/sq. ., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank•pres nt? ❑ Yes ❑ No Non-sanitary waste discharged o the Title 5 system? ❑ Yes ❑ No Water meter readings, if av 'able: t5ins-3/13 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name. information is required for every Osterville MA 02655 October 1;1 2016 , page. Cityrrown 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: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool` ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655_ October 1;1, 2016 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: System installed 9/25/1996. Certificate of Compliance on file at Health Dept. i Were sewage odors detected when arriving at the site? ❑: Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a ' Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 4 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: 10.5' x 5' x 5.5' 1500 gallons 3" Sludge depth: 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts , 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments { M ,..'' 33 Pine Lane Property Address { G. Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3" at inlet<1" at outlet t 6" Distance from top of scum to top of outlet tee or baffle 14 i Distance from bottom of scum to bottom of outlet tee or baffle I How were dimensions determined? Tape measure',and dip tube. I Comments (on pumping recommendations, inlet and outlet tee or baffle condition,,-structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Pumping not needed at time of inspection. { Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal: ❑ fiberglass El polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scu /t6p outlet tee or baffle Distance from bottom of'scum to bottom of outlet tee or baffle i I Date of last pumping: Date I t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts UpTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - , 33 Pine Lane Property Address i Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 111, 2016 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.): i Tight or Holding Tank(tank must be pumped.at time of inspection) (locate on si i.te plan): Depth below grade: f Material of construction: I - x t ❑ concrete ❑ metal; ❑ fiberglass ❑ polyethylene ❑ other(explain): I i i Dimensions: Capacity: gallons t Design Flow: gallons per day i Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition f alarm and float switches, etc.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 1.1, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0„ 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.): . One inlet, one outlet. No solids carryover or high water staining over outlet invert' No sign of leakage. Riser brings cover within 6" of'grade a Pump Chamber(locate on site plan): 1 Pumps in working order. El Yes, ❑ No" Alarms in working order: El Yes ❑ No* f Comments (note condition of pump hamber, 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: f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is Osterville MA 02655 October 11, 2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. 1-6'x 6'w/ 1.5' ® leaching pits number: of stone. ❑ 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:}: Leach pit dry at time of inspection. Light high water staining T from base. 4' below invert. No sign of past hydraulic failure Riser brings cover 12" below grade. f 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 f Commonwealth of Massachusetts Title 5 Official Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 page. Cityrrown 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 i/gnsof Depth of solids Comments (note condition of;slic failure, level of ponding, condition of vegetation, etc.): j 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official ;Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information`(cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately -S l tea = i J `/ I �> I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official ;Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owner's Name information is required for every Osterville MA 02655 October 11, 2016 - page. Cityrrown State Zip Code Date of Inspection D. System Informationj(cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells -Estimated depth to high ground water: >5feet 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: 09/09/1996 Date ® Observed site (abutting property/observation hole within 150 feet ofiSAS) ❑ Checked with local Board of Health -explain: + I ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGSI.database-explain: maps massgis state.ma us/oliver.php You must describe how you established the high ground water elevation: Slope to rear of property drops well below base of leach pit. Certification letter from engineer in 1996 shows adjusted ground water,, below base of leach pit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Pine Lane Property Address Adrienne Cozzolino Owner Owners Name information is required for every Osterville MA 02655 October 11, 2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i I 4 f f k I ' I _ t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH,OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 33:Pine Lane Osterville MA 02655 Owner's Name: Mar Isaacs Owner's Address: Date of Inspection:. October 12 2007 Name of Inspector:,(Please Print) James M. Ford 7,.` sr James M. Ford M1 Company Name 1 `' P.O.Box 49. I 1 Mailing Address: ' Ostervllle MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT . I certify that I have.personally inspected the sewage disposal system-at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the:proper function and 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 , N Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: October 16: 2007 The system inspector shall'sub a copy of,ihis inspection report.to the Approving Authority(Board of Health or DEP)within 30 days of completirig 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. Notes and Comments ` ****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 Inspection Form. 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Pine Lane Osterville, MA Owner's Name: Margaret Isaacs Date of Inspection: October 12, 2007 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: 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 detennined(Y,N,ND)in the for the following statements. If"not detennined",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 I xisting tank is replaced with a complying septic tank as approved by the Board.of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance . indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "PART A CERTIFICATION (continued) . Property Address:. .. 33 Pine Lane Osterville, MA Owner's Name: ', MarfzaretIsaacs Date of Inspection: October 12.`2007'_ C. Further Evaluation is Required by.the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. .* . 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within^50 feet of a surface.water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health.(and Public Water Supplier,if any)determines that the system is functioning in manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is mithin 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 I of a public water supply: ' The system has a septic tank and SAS and the SAS is I within 50 feet of a private water supply well. Y 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**. Methodused.to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen,and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 • Page 4 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: •33 Pine Lane Ostermille, MA Owner's Name: Margaret Isaacs Date of Inspection: October 12, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"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 town 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 _ ✓ Required pumping more than 4 tithes in the lastyear NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.. _ ✓ Any portion of a cesspool or.privy is less than 100 feet,but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,.for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (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. E. Large System: To be considered a large system the system must serve a facility.with a-design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 Pine Lane Osterville, MA Owner's Name: Margaret Isaacs . Date of Inspection: October 12, 2007 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 nonnal 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 detennined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation'of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6,of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 33 Pine Lane Osterville, MA Owner's Name: Margaret Isaacs Date of Inspection: October 12, 2007 FLOW CONDITIONS' RESIDENTIAL. Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd.x#of bedrooms): 220 . Number-of current residents: n/a Does residence have a garbage grinder.(yes or no): n/a Is laundry on a separate sewage system(yes or no):. No [if,yes separate inspection required] Laundry system inspected(yes,or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No. Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL . Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc:): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title"5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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 s 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: Installed on 9125196-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM T PARTS C SYSTEM INFORMATION(continued) Property Address: 33 Pine Lane Osterville, MA Owner's Name: Martraret Isaacs Date of Inspection: October 12, 2007 . BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC _other(explain): p Distance from private water supply well or suction line: Connnents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 15" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain). If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): '(attach a copy of certificate) Dimensions: 1500 izal. Sludge depth: 2,, ., Distance from top of.sludge:to bottom of outlet tee or baffle: 30" Scum thickness: I_" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottoin of outlet tee.or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.): F= Tees were present. The liquid level was even with the outlet invert. The outlet cover was ]'.`below grade. There did not appear to be any signs of leakage. GREASE TRAP: None (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(on pumping recommendations,inlet and,outlet tee or baffle condition,structural integrity,liquid levels as related to outlet.invert,evidence of leakage,etc.): Page 8,of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Pine Lane Osterville, MA Owner's Name: Margaret Isaacs ' Date of Inspection: October 12, 2007, TIGHT or HOLDING TANK: None (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/day Alarn present(yes;or no): Alarm level: Alarn in working order(yes or no); Date of last pumping: Conunents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Continents(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.): The D-box was level. No solids were present. PUMP CHAMBER: None. .(locate on site plan) Pumps.in working order(yes or no): a' Alarms in working=order(yes or no) Conn ments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 . . r Page 9•of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:, 33 Pine Lane Osterville, MA Owner's Name: MarQaretkaacs- Date of Inspection: October 12..2007 SOIL ABSORPTION SYSTEM(SAS): ✓F (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'(1000 a� l:) *, leaching chambers,number: leaching galleries,number: leaching trenches,,number;length:- leaching-fields,number,Ame_nsions overflow cesspool,number: Innovative/alternative system Type/name.of technology: Cotmnents(note condition of soil',signs of hydraulic failure,level of ponding,damp'soil,condition of vegetation, etc.): The pit was dry and clean. The scunr line was Pup from the:bottom. The cover was I5"below,trade.` There did not appear to be any signs of failure. CESSPOOLS- None (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: L Materials of construction: Indication of groundwater inflow(yes or no): Cominents (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,-'.etc.): PRIVY: None (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.): 9 r Page.10 of. 11 a. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Pine Lane Osterville, MA Owner's Name: A rzaret Isaacs Date of Inspection: October 12, 2007 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. 3 A. L3 / to 38 3 aY 3 10 f s„ ,Page 1 t of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: 33 Pine Lane Osterville. MA ` Owner's Name: Marjzaret Isaacs Date of Inspection: October 12, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35 +/- feet Please indicate(cheek)all methods used to determine-the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps; the n'zaps were showing approximately 35'+1-to ground water at this site. This report has been prepared.only for the septic system and components described herein. This septic system has been. 'inspected and passed as of the date of inspection: This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating.to the septic system, the inspection, this-report and/or any components of the septic system which have not. been located and inspected.' • t� Town of Barnstable ' �of ra,� Regulatory Services. r BARNSfABLE, Thomas F. Geiler,Director 9$ MASS ��� Public Health .Division AIEp�,�p, Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 - Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by.receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within,this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. ° f 6/28/02 D AT E : ----------- gpnpc [�Tv � p0RESS 33-Pine _Lane-- ----- --------------- Osterville Mass __-- - --- 1,/,f-dig 026°55 -- - -- ------------------- On the above date, I Inspected the septic system at the above adgftgEIVED This system consists of the following; 1 . 1-1500 gallon septic tank . JUL U 8 2002 2 . 1-Distribution box . 3. 1-1000 gallon precast leaching pit packed in 2 ' of 12 s t o eTOWNOFBARNSTABLE 6 'X 1 0 ' HEALTH DEPT. Based on my Inspection, I certify the following'conditlons: 4 . This is a title five septic system. ( 78 Code 5 . The septic system , is in proper working order at the present time . 6 . Pumped the septic tank at time of inspection .Heavy scum & solids layers were present . 7 . Waste water is 5 ' 6" below the invert pipe of the leaching pit . SIGNATURE :. NarT,e : ' _P_._ Maco=ber Jr Company ; Joseph -P _-Macomber-& Son , Inc . :address : Box 66 ----------------- -_Cencervilie _ _Ma , 02632-0066 Phone : 508_775_ 3338 __-_-- THIS CERTIFICATION DOES NOT CONSTITUTE A, GUARANTY OR WARRANTY f II JOSEPH P, MACOMBER & SON, INC. Tanki•Cesspools•Leachflelds Pumped & Installed Town Sewer Connections P 0. Box 66 Centerville, MA 02632.0066 775 3338 775.6412 COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL, PROTECTION 4 . TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 33 Pine Lane Osterville .Mass. Owner's Name: Andrew Hall Owner's Address: Same Date of Inspection: 6 2 9 02 Name of Inspector: (please print)Joseph P.Macomber Jr Company Name: J. P .Macom er & Son--Fn—c . Mailing Address: Box 6 Centerville .Mass . 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT " 1 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 rraining 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: �Zlpasses� _ Conditionally.Passes " Needs Further Evaluation by the Local Approving Authority Fails I Inspector's Signature: Date: The system inspector shall mit 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. Notes and Comments ****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 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Pine Lane stervi e , ass . Owner: Andrew Hall Date of Inspection: 6 29 02 Inspection Summary: Check A,B,C,D or /ALWAYS complete all of Section D A. System Passes: I have not found anv informations hick indicates that any of the failure criteria described in 310 CMR 15.30 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time . B. System Conditionally Passes: ADD 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: -t,4� 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: IV) 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: 2 Page 3 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem Address:33 Pine Lane Ostervi e , ass . Owner: Andrew Hall Date of Inspection: M9/02 C. Further Evaluation is Required by the Board'of Health:, /w Conditions exist which require funher evaluation by the Board of'Health in order to-determine if the system is failingto protect public health safer or the v P P y e en trorvnent. I. Ssstem 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 bealtb, safety and the environment: Cesspool or privy is within.50 feet of a surface water r Cesspool or privy is within 50 feet of.a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public,health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is`withut,100-feet of a surface water supple or rributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of.a.public water supple 1p The system has a septic tank and SAS and the SAS.is within 50 feet of a private water supply well. , IV2 The system has a septic tank and SAS and the SAS is less than I9P feet but 50 feet or more from a private ssater supplj well Method used to.determine distance 'This ssstem passes if the well water analysis, performed at a DEP cenified laboratory, for coliform bacteria and volatile organic compounds indicates that the weld is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are rriggered. A copy of the analysis must be anached to this form. 3. Other: .' 3 r 1 f Page : or ; OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Pine Lane OSY_Aryl l l e ,MAR.S _ . Owoer: AnrlrPw 14,gl 1 --- Date of lospection: 6,29g2 D. System Failure Criteria applicable to all systems:. You must andicale "yes" or—no- to each of the following for all inspections: i Yes !vo Yischaige ackvp or sewage into faciliry or system component due to overloaded or clogged SAS or cesspool or pondtng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level to th dismibutton'box above outlet inven due to an overloaded or clogged SAS or /cess ool j 6/fie/B/ ✓ P _ iquid depth in.te�Ls less than 6" below inven or available volume is less,than ''A day now equired pumping more than 4 times in the last year NOT due to clogged or obsrrueted pipe(s). Number — /or times pumped �. y ponion of the SAS, cesspool or privy is below high ground water elevation. Any ponion of cesspool or privy is within 100 feet of a surface water supply or rribumry to a surface water supply. ,An ponton of a cesspool or privy is within a Zone I of a public well. _ _ y ponion of a cesspool or privy is within 50 feet of a private water supply well. Any ponion of a cesspool or privy is less than 100 feet but gieater than 50 fect.from a private water supple well with no acceptablc water quality analysis. ITbis system passes If the well water analysis. pertarmed at a DEP cenified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate oitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis trust be attached to this forma (YcsNo) The system fails. I have determined that one'or more of the above failure criteria exist as � nbed in �10 CMR 15 303-ihcrefore the system fails. The system owner should contact the 5o5rc 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 now of.10,00o gpd to 15,000 ?Pa You must indicate either 'yes" or "no" to each of the following: (T*hc following criteria apply to large systems in addition to the criteria above) Nes no �c system is within 400 feet of a surface drinking water supply _ zlhc system is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen sensitive area (I-nterim Wellhead P7otectionzArea - IWPA)or a mappee Zone_II of a public water supply well !f yoc nave answered "yes" to any question in Section E the system is considered a significant threat, or answerea Nes" in Section D above the large system has tailed. The owner or operator of any large system considered a s:e.n.:ricant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR '04 The system owner should contact the appropriate regional office of the Department. 4 I Page 5 of I I h -t, OFFICIAL INSPECTION FORM --NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 Pine Lane Osterville , Mass . Owner: Andrew Hall Date of Inspection: 6/2 9/0 2 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 /1,Vere 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 pan,of this inspection ? jWere 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,'e�eecluding 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: Yin o Existing information. For example, a plan at the Board.of Health. Determined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)J 5 , . Page 6 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION Property Address: 33 Pine Lane Ostervil.le ,Mass . ; Owner: Andrew Hall Date of Inspection: 6 29 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): j- Number of bedrooms(actual): DESIGN,flow based on 310 Ci 15.203 (for example: 110 gpdx # of bedrooms):*J1C1�`.3-���' " Number of current residents: Does residence have a garbage grinder (yes.or no): Is laundry on a separate sewage system,( es or no):7R (if yes separate inspection required) Laundry system inspected (yes or no): � Seasonal use: (yes or no): ��• Water meter readings, if available (last 2'years usage(gpd)):1- - 04406 9�` Sump pump(yes or no): __WAAC C,4460.1 Last date of occupancy: , Z/ ' COMM ERCLAUINDUSTRIA L Type of establishment: ,d�Q Design now(based on 310 CMR 15.203): AR gpd Basis of design now (seats/persons/sgft,etc — Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: A/� Last date of occupancy/use: /lj$ 1 OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: 4_iZ4 Was system pumped as pan of the inspection (yes or no): If yes, volume pumped:/btu gallons •• How was quantity pump d determined? .W _ Reason for pumping: Pumped 1500 gallon septic tank . Heavy scum solids layers were present . ( Maint ) TYPE OF SYSTEM Septic tank, distribution box, soil absorption system ,40 Single cesspool 49-Overflow cesspool Privy 4,40 Shared system (yes'or no)(if yes, attach previous inspection records, if any) /W Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from syste, owner) Tight tank Attach a copy of the DEP approval /- Other(describe): Appfoxinrigike aoe of all 6Qmponents, date installed (if known) and s urce Of' f rm t 9,6 Were sewage odors detected when arriving at the site(yes or no)_�P 6 Page 7 of I 1 h: OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conti`nued) Property Address:33 Pine Lane - s stervi e , ass: owner: Andrew Hall Date of Inspection: r BUILDING SEWER (locate on site plan) .. Depth below grade: Materials of construction: _cast iron 40 PVC, )other(explain): .�/�" ' Distance from private water supply well or suction line: "e I- a Comments(on condition ofjoinu, venting;:,evidence of leakage,etc.): Joints appear tight . No evidence, of leakage .The syste'm_ is vented through the house ,—vents . SEPTIC TANK: —L/(Iocate on`site plan)Id�l / 'S Depth below grade: Material of construction: A"concrete f metaLU�fiberglass,�olyethylefie /!! other(explain) If tank is metal list age: Is age-confirmed by a Certificate of Compliance(yes or no):,Vff{attach a copy of certificate) Dimensions: l0�6i��. Sludge depth: Distance from top of slu ge to bottom of outlet tee or.baff]e . _= �. Scum thickness: Distance from top of scum to top'of outlet tee or baffle: r e Distance from bottom of scum to bolt of outlet tee or baffle: How were dimensions determined: �s� ✓ 9r .a ,� i� i.� . '.C1�.��J Comments(on pumping recommendat orfss,.inlet and outlet tee or baffle condition, structural integrity, liquid levels. as related to outlet invert, evidence of leakage;-etc•): Pump the septic tank every 2-3 years Inlet •& outl6t tee"s are ; n place The ank - is structurally sound and shows no evidence of leakage . _ 4 w B i Y GREASE TRAP4,"Iocate on site plan) ` , Depth below grade: Material of construction',aconcrete,4metal.fiberglass f/A� lyethylen*4,Pother : (explain): Dimensions: Scum thickness: �„ 4F Distance from top of scum -to top of outlet`tee'or baffle: Distance from bottom of scum to'bottorritof outlet tee or.baffle. ' Date of last pumping: . .Comments(on pumping recommendations;inlet and outlet tee or baffle condition,,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): , Grease .trap i-s' .:not .prese`nt . 7 I - Page 8 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Pine Lane Ostervi - Mass , Owner:Andrew Hall Date of Inspection: 6/29/02 TIGHT or HOLDING TANY,/ -,(tank must be pumped at,time of inspection)(locate on site plan) Depth below grade: r)A Material of construction: 1concrete metal 4�4 fiberglass,,&W Polyethylene4other(explain): Dimensions Capaciry: gallons Desien Floe: I gallons/day Alarm present (yes or no): off Alarm level: 1 Alarm in working order(yes or no): Nit Date of last pumping: M_ Comments (condition of alarm and float switches, etc:): ig t or holding tanks are not present . 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.): Distribution box has one lateral . No evidence of solids carry over . No evidence of leakage into or out -ot the box . PUMP CHAMBEP4, ,(locate on site plan) Pumps in working order(yes or no): /L Alarms in working order(yes or no):�y Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is Alot present . 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Pine Lane stervi e , ass . Owner:Andrew Hall Date of Inspection: 6 29 02 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not requirTQ 1-1000 gallon precast leaching pit packed in 2 of12 stone . ( 6 X1( If SAS not located explain why: Located ; See page 10 Type , leaching pits, number: % _L,Q leaching chambers, number.Z) leaching galleries, number: A4 leaching trenches, number, length: d leaching fields, number, dimensions: _a C7 overflow cesspool, number: Q 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.): Loamy sand to fine sand . No signs of hydraulic failure or ponding . Soils .are dry . vegetation is—normal. CESSPOO -(cesspool must be as art of inspect locate pumped, , P p )( on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum laver Dimensions of cesspool: Materials of construction: Indication of groundwater infow,(yes or no): / Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .Cesspools are not "presen . PRIVYt,A/4(locate on site plan) Materials of construction: ��r9 Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): Pr'ivv is not present t 9 Pagc 10 of I I 0FFIC1,4_L INSPECTION FORM — NOT FOR VOLUNTARY AS SUBSURFACE SEWAGE DISPOSAL SYSTEM 1NSPEC7ION FORM PART C SYSTEM INFORMATION (continucd) Pfoperr7 Adorc,1:33 Pine Lane stervi e , ass . , ` Oxocr;Andrew Haii 01 of Inlpcctioo; v/ T77 02 SKrTCH OF SFWACC DISPOSAL SYSTChl Pto.iot i Iknch of iht 1`41( 4iIpol1l Imcm Inclvding tics to Locic tl1 cllI .,ih It Ic43l rwo permancnl frcfcrcncc IdnCmuk, o o<nc+vnvki .. ;n f00 (<<t. LOCIIc whcrc public witcr rvpply cntcrs the bvilding. ` I IR out .. 1 � q Ifl m V m D_ �D m TOWN OF BARNSTABLE f c LOCATION 33 �^e L�n� SEWAGE # -LA4 � f 011 VILLAGE Q 5 0l (�y�l�(; --ASSESSORS MAP& LOTZI'> &" ,V _ INSTALLER'SNAME& PHONENO. L��'Sb`-to SEPTIC TANK CAPACITY l5"�o G ert� LEACHING FACMITY: (size) 100OG•sl.� NO. OF BEDROOMS ;.3 BUU-DER OR OWNER Ar cmexli A\ l T ' PERMIT DATE: --pT%—)g L� COhIPLIANCE`DATE: Separation Distance Between the: MaXMtmm Adjusted Groundwater Table and Bottom of Leaching Facility Flee ' w Private Water Supply Well and Leaching Facility (If any wells exist Cr on site or within 200 foot of leaching facility) Feet _ wEdge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Cr J Furnished by _ �%�Z1�P�'>� D' 0 (} . 'x m ru c- 1 1 a _ Z JJN-24-2002 11:02 COTTON RERJ ESIH E '508 420 8946 P.05/05 i i 1 U-' IS w e y P TOTAL P.05 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 33 Pine Lane stervi le ,Mass . - Owner: Andrew Hall Date of Inspection: 6 2 9 0 2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7,v feet Please indicate(check) all methods used to determine the high ground water elevation: y U Obtained from system design plans on record If checked,date of design plan reviewed: 6/2 8/0 2 y_E.S Observed site(abutting property/observation hole within 150 feet of SAS) y P.S Checked with local Board of Health-explain:obtained as built card YES Checked with local excavators, installers-(attach documentation) . YES Accessed USGS database-explain:htt p : 11 town .barnstable .MA u . s . You must describe how you established the high ground water elevation: Used ; Gahrety & Miller Model . 12/16/94 Gro6nd water elevations above sea level . Used ; USGS Observation well data . June 1992 Used ; Technical — — 2 ranges of groun rwa er elevations . Leaching Pit t,,eet Groundwater t=eet Below Bottomlof Pit AiO,Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is 47, ZZ) feet. 11 Rrnr-r—n:•r►—•+r—irn—mr•nfnr'a—rtr..rm.rr.R:•n.+•nmrr�+r*srn•+,rrs�ti**v�+Tm r+r .. .�' t' Barnstable 1'UNN OF WARD OF 11EALT11• j SOBSURFACF ,SFNACF DIS NSAL SYSTEM INSPFCTION FORM - PART D •- CERTIFICATION s'1•T••••..—�.::f.�.�.T.T.1,•R:Rri T'1T:RTtflTT1't—•.•t^I:'TP71TRtC1—TmeflR�f�T , -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 33 Pine Lane Osterville , Mass . ' ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Andrew Half PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J.P.Macomber & Son Ines ' COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street To vn or City State LIP COMPANY TELEPHONE (508 I 775 - 3338 FAX ( 508 ) '7,90 - 1578 R CERTIFICATION STATEMENT I certify that I have personally inspected the s.ewage `disposaj system at this address and that the i n f o r m t ation reported is rue , accurate , and omplete as of the time of :inspection . The inspection was performed and a I recommendations re ardin u ny g g pgrade , malntennnce , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : _jZ1Sys tern PASS-ED The inspection which I have conducted has not found any information which indicates that 'the' system fails to adequately protect public healLll or the environment as defined in 310 CMR 15 , 303 , ,Any failure' criteria not evaluated are as stated in the FAILURE 'CRITERIA section of this form , System FAILED* The inspection which I have con "U'cted has found that 'the. system fails to Protect the h.tiblic -health. and the environment in accordance with Title 5 , 3.10 CMR 15 , 3031 and ' as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature �d} Date jn6 erepe of this rt.ification must be provided to the OWNER, the BUYER }�plicable ) and the BOARD OF HEAL'I'll, * If the inspection FAILED , the owner or1•oparator shall upgrade ' aYate within one year of the date of the inspection , unless allowedorthe requiredm otherwise as provided in 310 ChJR 15 . 305 . partd .doc � ( n la PARCEL N0• O R Fee No. ier THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Mizpogar *p!5tem Construction 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. 7 -OJ I. Installer's Name,Address,and Tel.No. Lf �S(� 0 Designer's Name,Address and Tel.No. �0 2Do n�c,n� v�^ ✓S�'�'i����. � II Type of Building: Dwelling No.of Bedrooms 21 Garbage Grinder( ) Other Type of Building 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 w,jen applicable) 640CRA4e /5-0064/ 4 too o cal d iee,69,?' d l%- /4 "57Zie — :&".s7b,? f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this B ar Signed Date b Application Approved by Application Disapproved for the following reasons Permit No. e Date Issued /- •� x,,�r4 -r*�C��4`iv�•�' •tirsYaYi� 'xttd� r //� i .. . i. ,.. - P z No. "Q Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS C i 01ppYication for Mizpozal *p.5tem Conttruction' 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. t,V, 14hoee<j 'A (,no �r� OAT. Installer's Name,Address,and Tel.No. L Designer's Name,Address`and Tel.No. . l Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building 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) v .1 — O — l7is/ r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system , in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi cate of Compliance has been issue y this Board ealth. Signed. Date `� . O Application Approved by Application Disapproved for the"following reasons Permit No.% CS Y"7S Date Issued ,t THE COMMONWEALTH-OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the O -site Sewage Disposal System ins lied(^p)or re-paired/epl c.d on by for L.•�2 I I as ' - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ^ dated Use of this system is conditioned on compliance with the provisions set forth below: - 15 n No._ =—�� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mfi5pogal 6pgtem Cott!5truction permit Permission is hereby granted to G02_0o 1'_BU nApv } to construct( )repair( �n On-site Sewage System lockited at 33 )l7 /4a e 037c,-,, t 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. ! f All construction must be completed wain two years of the date below. oe Date: r " Approved b _ i FOR A DISPOSAL CERTIFICATION OF SKETCH AND APPLICATION WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated _S �% /l'�'� , concerning the property located at ����� e l-+ po1 e� �s e�,.�`I a meets all of the following criteria: • 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 • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: > LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. �. � � �. I I � ,. r � - - � � � � ; -� , � 1 � (�. _ � � _ � � �J1 G Q /� Q 9 �' f � a '� � � ''" � 1 - . � � ~ i n I � � � I s- i i ---..�- i TOWN OF BA.RNSTABLE LOCATION Pot- /4A(— SEWAGE# VILLAGE 0 S rerVJ4 ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY SUb LEACHING FACILITY:(type) (size) a'SrO/U- NO.OF BEDROOMS OWNER SSA CC f PERMIT DATE: COMPLIANCE DATE: 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) [' l Feet FURNISHED BY T�lfpCLTiw� J 1 a/�C f. 3 r. A C3 30 y Y TOWN OF BARNS-TABLE LOCATION SEWAGE # VILLAGE Z�W5�r_ ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. -- s SEPTIC TANK CAPACITY LEACHING FACILITY: {type)147'6401DhJ �M`o (size) NO. OF BEDROOMS - — BUILDER OR OWNER �— PERMIT DATE: 9—��— / - COMPLIANCE DATE: 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 eac 'ng Facility ( y wetlands exist within 300 le ility) Feet Furnished r c x, r r �I C TOWN OF BAR.NSTABLE LOCA•iION \ ,r� � SEWAGE # LA LA VILLAGE �'�`�`��� ASSESSOR'S MAP&.LOTS/ ?—0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �JC�C G P'f1t LEACHING FACILITY: (type) `�GAS��� (size) fiC?®O G'9�`� 5�kc�. NO.OF BEDROOMS E QQ rtAl t BUILDER OR OWNER 6 t*\ORe"J 1 T R PERMTTDATE: S EP / M4 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 facility) Feet Furnished by "'- P �A 7- toiQQ �` i " t i TZ I `mi - IN ;'�Inlll nlli I ,II, i:IIII I;11 it It kZP I �v a _ < $ F t� Ac Ap ;I i s _ ... .44 - - - - i i-- - -------------- I il.l 'g ,f I i 44 _ I 1 ij