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HomeMy WebLinkAbout0049 SYLVAN LANE - Health 49 Sylvan Lane �{ . M1 OstemMe P , A = 140 190 y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara &Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any - way. Impotent: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills _MA 02648 reRP" City/Town State Zip Code 508-428-1779 S► 12855 Telephone Number License Number B. Certification LU 1 certifythat I have personally inspected the sewage disposal system at this address and that the t M 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 (31-0 CMR 15.000). The system: U— C> 0-1 t L:�-. ®I Passes ❑ Conditionally Passes ❑' Fails y �— n7 /❑ deeds Further Evaluation by th Local Approving Authority 1 � i November 18, 2011 Job# 11-205 In ector's gnature 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. 11-205 David 49 Sylvan.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara&Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. CitylTown 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: Tank is not in need of pumping at this time pit shows no signs of hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 11-205 David 49 Sylvan.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara& Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety 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 a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Sylvan Lane Property Address Sara& Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. t. 3. Other: , s Y D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® ° Backup of sewage into facility or system component due to overloaded or - clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters - due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ® than_day flow Required pumping more than 4 times in the last year NOT due to clogged or -,E 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. 11-205 David 49 Sylvan.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Sylvan Lane Property Address Sara&Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 11-205 David 49 Sylvan.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara&Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ . ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 49 Sylvan Lane Property Address Sara &Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara&Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,,date installed (if known) and source of information: Compliance date: 10/28/98 Were sewage odors detected when arriving at the site? ❑ Yes ® No 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara &Jerry David Owner Owners Name information is required for Osterville MA 02655 November 18, 2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 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 -------------------------------------------------------------------------------------------------------------------------- Y 10.5' long x 5.8'wide- 1500 gal. Dimensions: Sludge depth: - 2" Distance from top of sludge to bottom of outlet tee or baffle 30" 2 Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara&Jerry David Owner Owner's Name information is osterville MA 02655 November 18, 2011 required for — every page. City/Town State Zip Code Date of Inspection D. System Information cont. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are intact and clear, liquid level was found at bottom of outlet invert. Tank is not in need of pumping at this time Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): p Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 11-205 David 49 Sylvan.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara &Jerry David Owner Owner's Name information is Osterville MA 02655 November 18, 2011 . required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present mustbe opened) (locate on site plan): 11 Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present Liquid level at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 49 Sylvan Lane Property Address Sara&Jerry David _ Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 _. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 600 gal pit. ❑ 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.): Pit had no standing water at time of inspection and no definite high stains, pit shows no evidence of hydraulic failure. 11-205 David 49 Sylvan.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara&Jerry David Owner Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions — Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 11-205 David 49 Sylvan.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara & Jerry_David Owner -- Owner's Name information is required for Osterville MA 02655 November 18, 2011 every page. CityRown State Zip Code Date of Inspection D. System Information (cost.) 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. 22 ! ! ! 16 NNN 14 !`! Water 16 Service Sylvan Lane Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane Property Address Sara&Jerry David _ Owner Owner's Name information is Osterville MA 02655 November 18, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el 5 and topo map shows property at el. 30. 1 11-205 David 49 Sylvan.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form" s Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 62655 Property Address `M a Rosemary,Sheehan 10 -` Owner Owner's Name information is 70 Walnut.Street, Arlington MA 02476 April 2'�2008 required for g P every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important:When filling out A. General Information W forms on the computer,use 1 Insp�Ctor: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA- 02648 Cityrrown State Zip Code 508-428-1779 Telephone Number License Number r 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority %M 0 April 2, 2008 Inspector's Signature Date • The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *.***This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 08-74 Sheehan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is required for 70 Walnut Street Arlington MA 02476 April 2, 2008 every page. Cityfrown 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 Pass',c: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, pit shows no signs of hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-74 Sheehan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form., Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street, Arlington MA 02476 April 2, 2008 required for 9 p every page. Cityr town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): .❑ distribution bo)6s leveled or rep'aced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑' broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1: System will pass uniess"Eioaird 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 a manner that protects the public health, safety and environment: ❑, The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-74 Sheehan.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street,Arlington MA 02476 April 2, 2008 required for g every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): . ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: .You must indicate"Yes" or"No4' 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool a ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool a ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow I . El ® 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. 08-74 Sheehan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is required for 70 Walnut Street Arlington MA 02476 April 2, 2008 every page. City(rown State Zip Code Date of Inspection B. Certification (cont.) D System Failure Criteria Applicable to All Systems cont. : Y �� Y (cont.): -Yes No ❑ ® 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. El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large-systems, you must indicate either"yes"or."no"to each of the following, in addition to the - questions in Section D. Yes No ❑ ❑ _ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 08-74 Sheehan.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 , f i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street, Arlington MA 02476 April 2 2008 required for 9 P every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes -No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Cl 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)] 08-74 Sheehan.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form 5i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is April 2, 2008 70 Walnut Street, Arlington MA 02476 A required for g P every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: '--N umber,of,.bedrooms(des:ign): 3 Number of bedrooms (actual;: 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 74,000 gal. _ 9 ( Y 9 (gpd)): 101 gpd. Sump pump? ❑ Yes ® No f Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow=(based on.310 CMR 15!2.03): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-74 Sheehan.doc-08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street,Arlington MA 02476 April 2, 2008 required for 9 p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: 3 Source of information: None 4 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 10/28/98 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-74 Sheehan.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is required for 70 Walnut Street Arlington MA 02476 April 2, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1 _ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from,private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' 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 El.-No' •-------------------------------------------------------------------------------------------------------------------------. Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 211 Distance from top of sludge to bottom of outlet tee or baffle 30" 2" Scum thickness 6 Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured 08-74 Sheehan.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street, Arlington MA 02476 April 2, 2008 required for 9 P every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are intact and clear, liquid level was found at bottom of outlet invert. Tak is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom'of scum to bottom of outlet tee or baffle Date of last pumping: Late Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 08-74 Sheehan.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is required for 70 Walnut Street Arlington MA 02476 April 2, 2008 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: • gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): 01. 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.ieakage,into or out of box, etc.): No solids or high stains present. Liquid level at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-74 Sheshan.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 2, 2008 April 70 Walnut Street, Arlington MA 02476 required for 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 600 gal pit. ❑ 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.): Pit had no standing water at time of inspection and no definite high stains, pit shows no evidence of hydraulic failure. 08-74 Sheehan.cloc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is April 2, 2008 70 Walnut Street,Arlington MA 02476 - A required for 9 p every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-74 Sheehan.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street, Arlington MA 02476 April 2, 2008 required for 9 _ P every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate-where public water supply enters the building. 22 16 1 j4 Water 16 Service Sylvan Lane Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface System Disposal Sewage Dis S g p y em Form Not for Voluntary Assessments 49 Sylvan Lane, Osterville MA 02655 Property Address Rosemary Sheehan Owner Owner's Name information is 70 Walnut Street, Arlington MA 02476 April 2, 2008 required for 9 p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check.Sl pe ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers (attach documentation) ® Accessed USGS database-explain: USGS trp6 map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 5 and topo map shows property at el. 30. 08-74 Sheshan.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Of THE t� Regulatory Services BARNSPXBM ; Thomas F. Geiler,Director 9$ M 16 ,�� p,E 9. Public Health Division 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. TOWN OF BARNSTABLE LOCATION I—! 5 V I van Lei # 5� VILLAGE `�<�� ASSESSOR'S MAP&PARCEL 'S NAME&PHONE NO. Tr�( L (3 :O At /77 SEPTIC TANK CAPACITY /UUQ LEACHING FACILITY:(type) PI-t (size) OD od NO.OF BEDROOMS OWNER \ ,\A ff PERMIT DATE: O-@ DATE: ✓►5P Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY . 4f4f\f\/\/4/\/\f4f\t\f\I\/\f4I4J4f4 r4/\f\fl 4r\r\J4r4r4r 4/4J4r4r4f`f4J\/4/4/\/\{4{4f4f 4/4{\/\/\f\14/\/\J414f♦•\r\f\,\{4/4r+•f\f\/ 16 . / F f f f •. \ \ \ \ \ \ 4 ! r ! f f f f J \f\/\r\r4/4f4r4J4f4/4/4/\/ r .. 14 \ \ \ \ \ \ \ \ \ \ \ \ \ r r ! f ! r r r r r r s J Water 16 Service Sylvan Lane TOWN OF BARNSTABLE LOCATION t"I �'�1 ✓I(0cp�\ 1. SEWAGE# M, VILLAGE C)S%-kru AU ASSESSOR'S MAP&PARCEL' Ii �S NAME&PHONE NOr, k-��r" Lk- �p�yru�t1 Lf' &-n1 g SEPTIC TANK CAPACITY i S0O qJ LEACHING FACILITY:(type)" i"T' (size) tpW NO OF BEDROOMS OWNER PERMIT DATE: � E DATE:`�,a.SP. 108 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) - Feet Edge of Wetland and Leaching Facility(If'any wetlands exist within 300 feet of leaching facility) ' Feet FURNISHED BY 22 � r i6 14 jl 16 •Wav Sary Sylvan Lane TOWN OF BARNSTABLECi' LOS�ATION 49 SYI VAN 1 NNE SEWAGE # q@ 613L VILLAGE 9( MII I I- ASSESSOR'S MAP & LOT '--I,, - 126 INSTALLER'S NAME&PHONE NOELLIS BROTHERS CONST 162-62.17 SEPTIC TANK CAPACITY 1 S®n LEACHING FACILITY: (type) C6ss e0aI, (size) T x NO:OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: 10 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 a Am 0 o '�e � �i2-owl p� �oosf 5 AMA) ��� R_ gn 'yNo. � v � Fee � t� � ��/d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Digozai *potem Congtruction Permit Application for a Permit to Construct ,,)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Yap/Parcel or Lot N Owner's Name,Address and Tel.No. ' 1f,v.V+ ds N.►.�/ h�j,►o lta/l ) f�/L2/Soil Assessors �j��ilJ IAI jC �s .� m A, 01 Installeer's,Name,Address,and Tel.No. Designer's Name,Address and Tel.No. h, er� Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building ,.Cep s No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 y 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 Nature of Repair or Alterations(Answer when applicable) /� /,o w (� 13,.k 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 Tit of the Environm tal Code and not to place the system in operation until a Certifi- cate of Compliance has been i sue is Board of pre Signed Date Application Approved by Date Application Disapproved fort folio ng reasons Permit No. ro a Date Issued No. ' (O/d 4v Fee THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: -, Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Zipprication for Mgpdngar *pgtem Conotruction Permit A Application for Permit to Construct(X Repair pp ) p ( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location 6d dre or Lot No. Owner's Name;Address and Tel.No. t b f' g J— 37�71 (y.��,�� , ag,7~1`/� Ljt�0 , �GGlii.cl f122/Sort Assessors ap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C--?�4ii J /Z,a,o s . wA�W Type of Building:° Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(/&Y Other Type of Building it2—f . No. of Persons Showers( ) Cafeteria( ) Other Fixtures a� Design Flow ! 3 V gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank r / / sue-' Type of S.A.S. Description of Soil Nature of Repair�ss or Alterations(Answer when applicable) � /� /A �. i 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 Tit .• of the!Environmedtal Code and not to place the system in operation until a Certifi- cate of Compliance has been iakue is Board of Pdaaly. /• �.r..2-2 J y C Signed Date 7 a Application Approved byf r ` ' y Date /0) Application Disapproved for the following reasons Permit No. - ro q Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(4)Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. c Date w �� Inspector •, -"w;_`4 --------------------- ------— No. / � / dL � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS C3� 3i5po5al *pgtem Congtruction Vermit Permission is hereby granted to Construct( )Repair(.)Up.r de( Abandon( ) System located at :;e f fy 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 musts be completed within three years of the date o is permit. Date: 1 0 47 7 5 Approved by �a No. / —6/�c Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: —NZ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS_ Appticatio'n for Mi-4pogaf 6p.5tem Con.5tructi.on Permit Application for a Permit to Construct(k)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Mdreo or Lot N9. Owner's Namev Address and Tel.tjo. .S o 77 Z y— 3271 j9Al 2w+ lii.il/�i(.0 lyj l0 � Assessor s'M ap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C if// V IZA"S • 6--" �- it/ e V Type of Building: Dwelling No. of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(le-� Other Type of Building . f . No.of Persons Showers( ) Cafeteria( ) Other Fixtures -1 Design Flow 3 V gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank h / - /s� Type of S.A.S. Description of Soil Nature of Repaid or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Tit of the Environm tal Code and not to place the system in operation until a Certifi- cate of Compliance has been i sue is Board of a". Signed Date ` Application Approved by 30 Date /_0 Application Disapproved for tWfolloAng reasons Permit No. � =�2�a- Date Issued -------------------------------- - ------ ME Cv`MMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for D)sposal System Construction Permit No. dated Installer .. �f—µ< /I Designer The issuance of this permit shall not be construed as a guarantee that the system.wd function as designed. Date � .. `r �Q Inspector * /J 10/9/97 NOTICE: This Form Is To Be_ Used For the Repair Of Failed Septic Systems Only. ` t f CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) Z� , hereby certify that the'application for disposal works construction permit signed by me dated D ���� , concerning the property located at `� Z�/�)V IWO 05;Z✓//� meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation (according to the Engineering Division G.I.S.map) _ B)Observed Groundwater Table tion(according to Health Division well map) � SIGNED . � DATE: LICENSED SEPTIC STEM 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 q:health folder:cert �� .�� ti' f� +'-� �� --..ia �'" U � �� C� J l//. 'n.NV Y ��..// Ii iVv �I ,�G�t1" 1 V� �� Vr �i� ��� CNIHNEY Yp x r'1 . w.L.Sala61"ES 5•T.w. li New ASPHAL(SIIIIYS —�� —-- — -- -- ----- - -- �� P•T.wo,pEava31��,I }.r wooD r ® �I14. -...... sta.w.oE I)M ® -iw im PAalL ® ® — It II 11 II - _11 IDI�TAYK NLYDNO)1 AM 77. wmo, - r - I I'I i Ta`l t 171 i , ' I III I• -_ 'I I WALL OEYONO I FS -- yNI 1 plclC I I NkL.gS 5'T.W. 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J I FAN 60.D.4I:•Mr4. 0 uEARArI[.C) BATH �JEDKOoM L �c, QLI y�-rlo� '�j %v�u�/ ��'� w.C.LN•r+trLCs f 1/4"_I'o' 5'T.w { hc,I lonl To ip49 ,YwAt4 I•AtJE 1 OS'(E(-VII,I.EI Mn Y� � ' suLe: l/4•-1=0•' ^"^Ovl[om: onwwn er Comm�t '� .y4'•I-o I`I(�}f-( 171DE [iI,EVA'(IDt.1 o,••E: y_27•w NE�.eeo 1/4 •1'•p' ADDITION ONLY owwwwa nuNeen IoFI COMMONWEALTH OF MASSACHUSETTS - EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIOE TITLE 5 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS'1 SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A uLe 2 6 2002 CERTIFICATION TOWN OF BARNSTABLE Property Address: 9 _ f��� _ HEALTH DEPTsrlernywr Owner's Name: Ark L_a1�Tarc Owner's Address: ?p P,r,>C a West Barmli&AA o 16 MAP Date of Inspection: 1131 oa' PARCEL 9 -- Name of Inspector:( ease print) R E I D C. E L L I S Company Name: T L L I S S LOT _—"— Mailing Address: _ 23 ENTERPRISE ROAD,. P.O. BOX 59 ,YARMOUTH PORT, MA Telephone Number: 5 0 8-3 E 2-62 37 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: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 1 `-XX�� Date: IQ, ' \00 O 2 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. 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 I raga t to 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: tii . Owner- iiLb CouT+�re Date of Inspection: 0113 IcL Inspection Summary: Checld ,C,D or E t ALWAYS complete all of Section D A. System Passes: u 1 have not found Iany information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CUR 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. i Answer yes,no or not determined(Y,N,ND)in the 1for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old'o;the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or"filtration o 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 wilt.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 hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven istribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are laced obstruction is remo red distribution box is*veled 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 placed obstruction is remo ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Lf q 15,uLVi4Vr 1.p m, Sexyi Owner:C ' ;nTL" r1 Date of Inspection: C. Further Evaluation is Required by the Board of Health: Iv J Conditions exist which require further evaluation by the Bo d 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 ac ordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect ublic 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 vegeti ted 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 hem Ith,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has'a septic tank and SAS and the SAS is w thin a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is w thin 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at�a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the wjll is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equil 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: .s 3 ragc�vi it OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L < %,1q" I-fkh£ Owner: d�ur i�+A Cv�re Date of Inspection:` — a/i 3/ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N� _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ ischarge 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 f c pool squid depth in cesspool is less than 6"below invert or available volume is less than day flow.: uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of es pumped y portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface supply. ortion 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 � mm are triggered.f copy of the analysis must be attached to this form.] A4L (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 Systems: To be considered a large system the system must sery 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 fol wing: (The following criteria apply to large sy stems in additionto 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 arch(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 Ithe system is considered a significant threat,or answered "yes"in Section D above the large system has failed.Tht 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 appropriat4 regional office of the Department. 14 Page'5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART R CHECKLIST Property Address: ®weer: jun4 uT�� Date of inspection: .4d: — Check if the following have been done.You must indicate` es"or"no"as to each of the following: Ycs:, N ` /umping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? v as the system received normal flows in the rev"— —� previous two week period . V Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built.plans p ans of the system obtained and examined?{1f they were not available note.as AIIA} 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,Qluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the Offles 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: Ye f 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 raged of I I OFFICIAL INSPECTION FORM®NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: It S�iL.tr l ftyh 1�STr�✓i!t _ >�11I ��1'�f Owner: A 14 Ca1 m"— _ Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CM R 15.203(for example: 110 gpd x#of bedrooms): 3 Number of current residents: O Does residence have a garbage grinder(yes or no): ,Vv Is laundry on a separate sewage system(yes no):,,_4_,_V[if yes separate inspection required] Laundry system inspected(yes or no): Al%4 Seasonal use:(yes or no): Water meter readings,if avdila b e(last 2 years usage(gpd)): G2A!X� 19,3 Sump pump(yes or no).-,&V I Last date of occupancy: Pan y' �#� ®L(i1✓�>� �-C1 . COZY MERCIAIJI"USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203) d Basis of design flow(seats/ ersons/s R etc. : P , Grease q ) trap present(yes or no):.� Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(ye g or no):— Water meter readings,if available: Last date of occupancy/use: t� OTHER(describe): Al IV GENERAL INFORMATION Pumping Records Source of information: C111V4X1z7WN` Was system pumped as part of the inspection(yes or no): �� If yes,volume pumpedgallons-�How was quant' pumped determined? U e yJ � Reason for pumping: �� � TAPE OF SYSTEM v 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): Ap roximate a�geofll components,date installed(if kno�and iource o information:O 28 r' 8 Were sewage odors detected when arriving at the site(yes or no): 0V 14t4lv/f 4 6'� 1 " i s �GL,¢-f -rAL q �o -- L)nMn // t.,. �c I/ 1 l f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lee Owner. � fl�Z C "Cur� Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: ��u Materials of construction: cast iron' 40 PVC____other(explain): Distance from private water supply well or suction line: c;;z ` 4 Commen (on ondi4on of joints,venting,evu nce of leakage,etc.): �. SEPTIC TANK: (' 4ocate on site plan) Depth below grade: 1 << Material of construction:Yconcrete—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) I 1 Dimensions: DA..6-A Y ' Sludge depth:__­3 Distance from top of sludge to bottom of outlet tee or baffle: y Scum thickness: 3 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outleptee or baffle:—42,-�ll How were dimensions determined: ykm Comments(on pumping cecommendatioias,inlet and outlet tee or bale c dition, a uctural ntegrity,liquid levels as related tp outlet i4vve�den of leakage,etc.): 2z ! N 0 NN i.1 C1 O GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: concrete metal—fit row,polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bafll Distance from bottom of scum to bottom of outlet tee r baffle: Date of last pumping: Comments(on pumping recommendations,inlet and cutlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): z ! 7 7 f - Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C1 <1 Ju--- Ut�10 Owner:, Date of Inspection: IA 3/cam n/ TIGHT or MOLDING TANK: (tank must be p ped at tune of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal 1 fiberglass_polyethylene other(explain): Dimensions. Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes orino): Date of last pumping: Comments(condition of alarm and float switches,etc. DISTRIBUTION BOX: (if present must be opened)(locate on site plan) 1 Depth of liquid level above outlet invert:-A Comments(note if box is level and distribution to outle ts equal,an evidence of solids carryover,q y arryo er,any evidence of leakage into or out of bo v e 4 0AZ4--,�fplr(/Jdi AK PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition�f pumps and appurtenances,etc.): - I ' 3' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner: Q�ada �t�'y��paY�('cxa"� '+ . Date of Inspection:SOIL ABSORPTION ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number._ leaching chambers,number: leaching galleries,number. leaching trenches,number,length: 4eaching fields,number,dimensionT------------- ovmgm cesspool,number: / . 4 s innovativelalternative system Type/naameof tdchnolo : Comments(note condition of soil s' �signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) CESSPOOL qOS, (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: l me- c2-s-.5 a/ Depth-top of liquid to,inlet invert: /6 Depth of solids laver: a �/ Depth of scum layer c- Dimensions of cesspool• Materials of construction: Indication of groundwater uzflow(yes or no): Comments(note condition of soil,,sigtts of hydraulic failure level of pon ing,conditionf�f ve e�s � PRIVY• (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydrauli failure,level of ponding,condition of vegetation,etc.): r Page 1,0 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) j Property Address: S►,lux�v� �,Q,� �/1/ Owner: a�vyara � Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM L Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locat e all wells within 100 feet.Locate where public water supply enters the building. Al C' Q vJ 4 oftt Gtj ' to6`' 'Po to, i can 3 . 41 i© _ .S�A . .►�l�f'1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM e PART C SYSTEM INFORMATION(continued). Property Address: S Owner:EJw( Y Date of Inspection: l J- 34sa- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6/2feet Please indicate(check)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) ecked with local Board of Health-explain: Checked with local excavators,installers-(attach documen ion) Accessed USGS database-explain: zP You must describe how you established the high ground water elevati a: / i A,A &-j-_ -t7o —t �Ce— 17>A-5� ems% 1-,eA>✓4-y'V � 0S, � TOWN OF BARNSTABLE " LOCATION 4q SYI VAN I-ANF SEWAGE # 99 692 VILLAGE gST�E-FBI-� ASSESSOR'S MAP & LOT L !�f b INSTALLER'S NAME&PHONE NOFLLIS BROTHERS CONST. 362-6237 SEPTIC TANK CAPACITY !5;®O LEACHING FACEL=: (type) C�S j°ooL' (size) A NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: W- COMPLIANCE DATE: 10 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 T' fez ok p �(OJSE t AT- TOWN OF BARNSTABLE — UNDERGR,OUND FUEL AND CHEMICAL STORAGE REGISTRATION do MAP NO. PARCEL NO., l ADDRESS OF TANK: �l 9 Lt �l/�v,-a �-�r� r? �.._� V,ILLAGE: � 1 MAILING ADDRESS ( IF D I FFEkENT FROM ABOVE) : ?, t.� �, w p r � ` y^J, j c OWNER NAME: fY 2 �9 e, ep, 1 k- 1 .S 0 l PHONE: . INSTALLATION DATE: INSTALLER ADDRESS: 'CERT.NO. *TANK LOCATION: J r 4 P)Asi .�0 r (owsonSac TANw LOQAT2ON W2TH PlCOP¢OT TO aU2LDSNO) CAPACITY -" ' TYPE OF TANK tJL'AGE YRS.. FUEL/CHEMICAL TESTING CERTIFICATION [ ] PASS [ A FAIL DATE LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION C ] YES [ NO DATE TO,IBE REMOVED; f �" FIRE DEPT. PERMIT ISSUED [ ] YES C ] NO ` DATE CONSERVATION C ] CHECK IF N/A DATE BOARD OF- HEALTH TAG. NO. [ ] DATE �l F a PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD �M A 0 v S I