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HomeMy WebLinkAbout0107 SOUTH BAY ROAD - Health 107,'-•SOUTH BAY R ppr� • q..«.p a Imo.. .` _ `OSTR1ZS�iLLIE n A'= 093- 066 0 TOWN OF BARNSTABLE 1 ' OLOCATION l6 S ��y �� SEWAGE # I VILLAGE ® 5 % ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY -ILO-0-0 LEACHING FACILITY: (type) �� C" L (size) zrd `l'" 1 ,3 NO.OF BEDROOMS C BUILDER OR OWNER �• .e a 1' PERMITDATE: / 4 -0/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater T e to the Bottom of Leaching Facility Feet Private Water Supply Well and aching Facility (If any wells exist on site or within 200 feet df leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by z � �,� �,� �.�. , � � !!! ` � s ! , E ©�,c0 �O TOWN OF BARNSTABLE a~ .LOCATION SEWAGE #,A.e� VILLAGE % ASSESSOR'S MAP & LOT>O.�dds�� INSTALLER'S NAME&PHONE NO. _Ts 6 , -8-5 d 7 S 77 4 i SEPTIC TANK CAPACITY LEACHING FACILITY: (type) !Y S "1 2 L.L (size) b 4 13 �. NO.OF BEDROOMS S G BUILDER OR OWNER. Z!5! PERMITDATE: —a G G COMPLIANCE DATE: S/-3` O - Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Le hing Facility Feet Private Water Supply Well and Leaching Facility (If wells exist on site or within 200 feet of leaching facility) Feet.. Edge of Wetland and Leaching Facility(If any Y r4lands exist within 300 feet of leachiT&facility) Feet Furnished by s i No. -too ZSY FVr 30 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS 01ppYtcation for Migooar *pgtem Con4ructfou Vermtt Application for a Permit to Construct( . )Repair(X )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 107 S Bay Rd. , Osterville Largay Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 6 Lot Size sq.ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system f o r 6 bedrooms, consisting of a 2,000 gal, tank, D—box and 4 precast leach chambers with stone all around. .14 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 issued by thi aid o ealth. Signed Date S-lil J Application Approved by Date 3 11 Application Disapproved for the following reason Permit No. Date Issued i v " t i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -l_Ke' 'l es PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Miopo!5al *patent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. X Owner's Name,Address and Tel.No. 1 nn�^7� /'Y��tr . 4 , Ass'esSoir's§ap 1 Rd. , Osterville 'u Largay Installer's Name,Address,and fel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Servic 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 8 Lot Size sq. ft. Garbage Grinder( ) Other Type of Buildin5 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 0'► gallons pe day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date` Title Size of Septic Tank —Type-of S.A.S. E Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 Lefft t or Date last inspected: �,S- X , • ( Z . Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B xd of alth. Signed Date—��-- :ry Application Approved by Date Application Disapproved for t e ollowing reason Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Largay BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )bye E. Robinson P_ , _ „_ ee at 107 6�.,y__Rd , 9ster T; , , e y has been constructed in accordance ` with the provisions of Title 5 and the for Disposal System Construction Permit No. 4- // dated T Installer Designer The issuance oT tA`per'moitphaaFl note c n§trued as a guarantee that the systr will function as designed. Date i / r Inspector ------------------------ ----------- No. 7,r/7 7.r/7� l� Fee$5 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Largay litpotar *p!5tem Construction Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 1 g 7 S pay i.Rd:�9gt�?ijx411 e 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. Provided:Construction must be completed within three years of the date of this permit. Date: :3 1/h�C/ Approved by rwl,; a!,-, r NOTICE: This Form Is To Be Used For the Repair Of Failed 4 Septic Systems Only. CERTIFICATION OF SKIS M AND APPLICATION FOR A DISPOSAL WORKS CONSTRIICTION PERAriI`'!'tVYrfHOUT DESIGNED PLANS) William E. Robinson,Shy certify dot the appiecation f x ,works consuvction permit signed by me dated lit -- e l , concerning the PioP" located at 10 7 S $aT Rd 0 s t o—r-i.1,i - meets all of the Mowing criteria: • The is cannt=d to a audestLial dwelling only. There are no commercial or business as= with the dwelling. The soil is as CLASS I and the pereotation rate is Um than or equal to 5 mimues per inch- - Them are wetlands within 100 feet of the proposed septic symem • There are private wells within 150 feet of the proposed Sepik s)stetu There is increase in loov anNor change in use proposed T hUe no vatianoes tegnes6ed or needed • The m of the proposed leacbittg faeiGty will Xbe located less than five foe above the ma adjusted fflum rdter table elevation-(Adjust the gtounthmer table using the Fnimptor when applicabiel If the S.A_S_will be located with 2%feet of my vegetatcd wetlands.the bottom of the proposed teachin@ fudity wilt rot be k=wd less than fountept t 14)fee above the mauironm adjusted groundwater tabk dwation, Please compkie the f dwwiag A) top of Gmund Elevation(using GIS ini oration) B l G.W.Elevation +Elie MAX. ttigil G.W,.Adjusunent DIFFERENCE BETWEEN a wd 6 — SIGNED DATE : - _(5 (Sketch pwposed FOR of system on bw*j. or heath foww.Cat � ,� . . . . _____ �� � i� � .l C � :t . �� - ---------- TOWN OF BARNSTABLE 5 ' J y SEWAGE # LOCATION j ASSESSOR'S MAP & 1,010 �d�i 4 VILLAGE ' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,I �or .� 2 L � (size) LEACHING FACILITY: (type) S i NO.OF BEDROOMS S— � ` i BUILDER OR OWNER COMPLIANCE.DATE: 3� O PERMITDATE:. . 'i Separation Distance Between the:. Feet Maximum Adjusted Groundwater Table to the Bo/tist hing Facility � ells exist Private WaterrSupply Well and Leaching Facili Feet qn site or within 200 feet of leaching facility Edge si Wetland and Leaching Facility (If any Feet within 300 feet of leachin&facilityy) Furnished by ri t. / �.. • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r RECEIVED MAY 292001 TOWN Or bARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 7 S Bay Rd. Osterville Owner's Name: Jack Largay Owner's Address: Date of Inspection: 4/-3-0 .� Name of Inspector: (please print) Wi 1 1 jam F._ Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: ( 508) 775-8776 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.1 am a DEP approved system inspector pursuant to Suction 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: w P t - , Date: �� -'4 7 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of 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 appro`.mg 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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 107 S Bay R d n-,tA,-viI le Owner: Date of Inspection: — Inspection Summary: Check A&,C,D or E/ALWAYS complete all of Section D A. Sys m 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 repa' d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indica . g that the tank is less than 20 years old is available. ND ex lain: Observation of sewage backup or break out or high static water level in the distribution box flue to-broken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstrmud pipe(s).The system will ass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 107 S Ra 3Z R d nRtnrvillo Owner: Date of Inspection: e — 1 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 fa ing 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. ystem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sys m 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 aseptic 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 front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 107 S Bay Rd. Osterville Owner: Largay Date of Inspection:�/3✓•� / D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes No / _ c/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 dogged 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'/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 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. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E arge Systems: T be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You mu t indicate either"yes"or"no"to each of the following: (The foil wing 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 ou have answered"yes"to any question in Bettina E the system is considered a significant threat,or answered "y s"in Section D above the large system has failed.The owner or operator of arty large system considered a s ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 1 304.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: 107 S Bay Rd. Osterville Owner: Larqay , Date of Inspection: 2-3 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 _ c/ Has the system received normal flows in the previous two week period? — ✓Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? — Were all system components,excluding the SAS,located on site Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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)J 5 Page 6 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 107 S Bay Rd. Osterville Owner: Date of Inspection: 4/—3—6 FLOW CONDITIONS RESIDENTIAL 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: a. Does residence have a garbage grinder(yes or no): 7L"- Is laundry on a separate sewage system(yes or no): X0 [if yes separate inspection required] Laundry system inspected(yes or no):, b Seasonal use: (yes or no):/t,d Water meter readings,if available(last 2 years usage(gpd)): 2 o o() 1 ()q ,()0 0 gal. Sump pump(yes or no):�'�- D 1999 360, 000 gal. Last date of occupancy: C MERCIAL/INDUSTRIAL Type of establishment: Desi flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sgft,etc.): Greas trap present(yes or no): Indus ial waste holding tank present(yes or no):_ Non- anitary waste discharged to the Title 5 system(yes or no):— Wat r meter readings,if available: Las date of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: c/1A Was system pumped as part of the inspection(yes or no):Al If yes,volume pumped:gallons--How was quantity pumped determined? Reason for pumping: TY �OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: y y Were sewage odors detected when arriving at the site(yes or no):its 6 Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 107 S Bay Rd _ Osterville Owner: Laraav Date of Inspection: 1/'3-0 F BU DING SEWER(locate on site plan) Depth elow grade: Materi is of construction:_cast iron _40 PVC_other(explain): Distan a from private water supply well or suction line: Co nts(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: l/(locate on site plan) Depth below grade: / Y 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: w L Sludge depth: 'L Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O Distance from top of scum to top of outlet tee or baffle: t tee or baffle: . Distance from bottom of scum to bottom of outlet �_ How were dimensions determined: /L Comments(on pumping recommendations,inlet and outlet tee or baffle.condition,structural integrity,liquid levels.- as related to outlet invert,evidence of lea age,etc.): GRE E TRAP:_(locate on site plan) Depth elow grade:_ Materi of construction:_concrete metal_fiberglass_polyethylene_other (expla' ): Dimen ions: Scum hickness: Dis ce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: D e of last pumping: mments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as elated to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 0 7 S Bay Rd. Osterville Owner: Largay Date of Inspection:U--3—o l T T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth elow grade: Materi 1 of construction: concrete metal fiberglass polyethylene other(explain): Dimens ons: Capaci •: gallons. Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date o last pumping: Comm nts(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: Comments(note if box is level and distribution to outlets equal,any evidence of.solids carryover,any evidence of leakage into or out of box,etc.): /d. Lew L1�3~-0 l PUMP CHAMBER: (locate on site plan) Pumps n working order(yes or no): Alarm in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 07 S 'gay Rd nstormr; 1 1 e Owner: T,arrtav Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic.failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inv Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR (locate on site plan) Materi is of construction: Dimen ions: Depth f solids: Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 0 7 S Bay Rd_ Osterville Owner: Largay 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. e iG U 1 J y O 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 107 S Bay Rd. Osterville Owner. Largay Date of Inspection: —3 `b l SITE EXAM Slope Surface water Check cellar Shallow wells w Estimated depth to ground water 1 feet Please indicate(check)all methods used to determine the high ground water elevation: Qbtained 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ho y u established the high ground water elevation: �G 6 L.- Ij $"d I d 70g� 'I 11 . ' TIDN TOWN OF BARNSTABLE UNDERGROU ND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER .AND INSTALLER INFORMATION ADDRESS: , , •.� .! /-' !` :'' `f` •a 4 d MAP NO. C0 lq I PARCEL NO. OWNER NAME: Z- !. . ,`',� ._) r�r .',//`�`r V I LLAGE: INSTALLATrION DATE: BY; A. ADDRESS-r:.t f ( CERT. NO. x r(�• *•.., ! /s woo, 7Y` 1 ANKINFORMA..' y,`' 4 k ,e.*Y•t 1"c 'S s+:;.. i;, ,, Y I .e?1, i rt=tA i tY { TION , LOCATION OF TANK: CAPACITY`W E tee,4 TYPE ! `> ' _ AGE J J,/,-2 FUEL/CHEMICAL TESTING CERTIFICATION C ] PASS [ ] FAIL . . DATE "' LEAKjDETECTI.ON �y7 CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION C ] YES z C'7J, NO DATE TO BE--REMOVED (,✓�M Y FIRE DEPT. PERMIT ISSUED C ] 'YES C ] ':NO DATE CONSERVATION - C ] CHECK. IF , N/A DATE BOARD OF HEALTH TAG NO.C ]C ]C ]C ] DATE ? PLEASE P>ROV I DE A SKETCH. SHOWING;;THE TANK_;LOCATION;ON THE BACK ;OF TH I S CARD w � r1 ... i�}r ♦.r..b�•<,.....�>,... � t;.:s. a? '.":i } .'`e:-.t_.,.,s";� ,. ':i .. o., s.;.r x i,.,,s .-.< ..a,..�-.txsr^...a.. � .a, .. ..,,. r::,ra.+5_ l�'4w ss.. e x .a. ...i�.:'_r.trt ._, tr` .w?