HomeMy WebLinkAbout0278 WIANNO AVENUE - Health 278 WIANNO AVENUE, OSTERVILLE
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LOCATION SEWA C F PERM NO.
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VILLAGE
IMSTA LLER'S NAME A ADDRESS
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\ BUILDER OR OWN ER
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DATE PE01MIT ISSUED
DATE COMIPLIAMCE ISSUED f
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'i<L�R GE . �AJSSESSOR'S MAP& LOT _
D-l"ST.kL:LER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �,,�,`/
LEACHING FACILITY: (type)o` l�`� d (size) ems,
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility Of any wells exist '
on site or within 200 eet of leaching facility) Feet
Edge of Wetlanj4ndfiaching Facility(if any wetlands exist
within 300 a cility) Feet
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TOWN,0F.BARNSTABLE
LOCATION �� (1)VC(V-JPJ0 SEWAGE #
VILLAGE �, _ VlA1l�. ASSESSOR'S MAP & LOT bO0
INS1 ALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 f�
LEACHING FACILITY: (type) (size) 000 00
NO.OF BEDROOMS
BUILDER OR OWNER
-PEFd41TDATE: COMPLIANCE DATE:
tt
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 2S.) Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) �0' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) N10c Feet
Furnished by, � °
y,
No...��.J�:. .. Fps.... ................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' .own.... ..........OF......Barnstable-...................................................
ApplirFation for Disposal Works Tonstraartinn ramit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
-•----W annQ••Aye... .Qst ryi l le............................. Lot 17 L.C:C_- 15 9 6 7 -E ...........
........
- ... -•---
Location-Addr,s or Lot No..
_ �..�..---.._..•-••-- --...-�/1 Lr .r. ._ . ....-� .vu.s..s. :.- ll pIh.
Owner Address
..�.i�.n�:.�r_ ne................................... .....:...........................................................................................
Installer Address 16762 q Type of Building Size Lot............................S . feet
Dwelling—No. of Bedroo_ms_______________________ ..........Expansion Attic ( ) Garbage Grindero)
Other—T e of Building _____ No. of persons_________________________ Showers — Cafeteria
04 Other fixtures ._ -----•------••.............. .........._...
W Design Flow...............5 ._.._.._. gallons per person �er day Total daily flow 4 4 0 gallons
----.._-•--
WSeptic Tank—Liquid capacity._),_5.0-gallons Length 0<."._.� _ Width 5 ®-. 'Diameter________________ Depth
x
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area.....................sq. ft.52.4.;
Seepage Pit No............. .. Diameter.......10.___--__ Depth below inlet_______.6__....... Total leaching area....... :=._.sq. it.
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed b}Qaa.P.e_._ Qd....S1 IZ.V.Q-y-...ConsultantsDate.......... -17-8-3...........
a
,,_� Test Pit No. 1.........2-.___minutes per inch Depth of Test Pit........ Z_.______ Depth to ground water_.._.none•---__.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
� ---------;------------------------------------------------------------------------------------------------------------------- 4 -M
O 7 .5.__-5.0_____med.___coarse_•y_ _ ..........
'����� �.---
Description.of Soil—Q. ,_,_ ...... lam_-- -
v arl�_:_rnr�. l�._. ar cQb _J, -►---5 t. .'.-12..0.'...med. white•sand. 4 . �.
1 -KE-N
W X------IZEBAGY
CIVIL
U Nature of Repairs or Alterations—Answer when applicable...........:.......... -=--- " 0 2980
Agreement: G.tF ST
The, undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accord SiiEe,C�
the provisions of L I s E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has)�n issued by the board of health.
Signed-- ....... .119--............ ...............--- ....:_5192.._....
Date
Application Approved By___ _ .���/� -----------
i
Date
Application Disapproved for the following reasons:-------•---••...---•-------••-•-------------•--•-•--••----•------•--•-•----•---------•-------•-•---------•-----
................•----•------...--•----------•---------------------------------•---------•---------------•-•------•...----------•-------------••---------••-----•---••••-----=•--•----•--------.....__._
Date
PermitNo......................................................... Issued.......................................................
Date
n
41
NO
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ToWn........................OF......Barnstable...................................................
Appliration for uiuvuual 30urk,5 Tunitrnrtiun Permit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
--• -w a mQ_ .v :.,. ?s ............................ .......... � �...... .,C.,.G� .7....F.......•.--.........----
Location-Add
r or Lot No.
S ...... .:s�.g -es x V ' c.................. .......44 bis .. _t .rxxd r#C..... a ....._....l .r... __....��
W is
owner Address
,a �Y �►- t=y; r:�.._.. q-44-"-04---------------------------------•- ......:...........................................................................................
Installer Address
Type of Building Size Lot__..-16. .....---------Sq. feet
U
�., Dwelling—No. of Bedrooms__________________________ _______________Expansion Attic ( } Garbage Grinder f10)
'4 Other—T e of Building ............... No. of persons......_................._... Showers — Cafeteria
Q' Other fixtures ............................ .
W Design Flow...............5 ._______ _-.-gallons per person �er,day. Total daily,flow............4_4fl........_------_•---_ Ions.
R: Septic Tank—Liquid capacit__12. _gallons Leng& t, = _ Width.5, ?Diameter________________ Depth..5.__8 _.
Disposal Trench—No..... ---------- Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No---------2. Dia meter.__...�.0�...._. Depth below inlet__...... '....... Total leaching area.52,4=`F} sq. ft.
Z Other Distribution box (X) Dosing tank ( )
aPercolation Test Results Performed b}Cap-e..Cad...S.ur ey--_-COMS-U antSDate.._....... ..........
1 Test Pit No. I.........2.....minutes per inch Depth of Test Pit-------12........ Depth to ground water.....n011e........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..__._...._.____.
RSq••--•-••••••-.-•----------------•-•-......-•--••---•----••--•--.....-----------_.�....••-••.....--••-••••--...------•---•-----.......... . �L
D Description of SoilQA.V 1..`� _....10m..and...subsoild �.� 5�� med....CpA.rg.e--y-_ s9
_...__aand... ith...sm.e... ...no d..... hIte..-.sand,................. ..... �...KENX R.
W -•--------------------------• .....----• -•--•-. =TEEBAGY
., ., fv
U Natur6kof Repairs or Alterations—Answer when applicable___ _________________________ .._
807
...........................----•--•-------•--•----•-----•-•---------•---------.._......---•----------------------------------------...-••-----1 . ... .•••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accorda
the.provisions of IT f.
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b�n issued by the board of health.
Signed ........................ ..... -- ...... ........
Date
Application Approved By..... ----•-••-•---•--••-•-•----•--•---• a -----------
Date
Application Disapproved for the following reasons:-----•---------•-•-------------•------------------------------•-----------------------------------•-••----------
.........................................•---•----------•---•----••---•-•.....------•---•••-------•-----..............................---•-----•----•-••-----•--•-------••-----•-•--••-•-•----------•-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
P� BOARD OF HEALTH
..........................................OF......................................I..............................................
Trrtif iratr of Tumpliatirr
THIS ISERT Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------------
..........-- ---
W Installer
at..................��/. --._....._- -•---•--•..... ...........J,r'-4 .......................------------------------------------------------.
has been installed in accordance with the provisions of TIT i 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...................;:.f.............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
SYSTEM WIL 9 FU/NCTION SATISFACTORY.
DATE.....?_ ..._ l__ ................................................... Inspector--- ----- ti._......._............--------•---------
�4
v
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C
No....5F?.e.z.. FEE........................
Eliupu, al Workii Tunutr ion "permit
Permission hereby granted F% ......C_��....."__�__.'_�_.,.-......•------------•-----------------------•---.......------........................
to Construct { ) or Re r ( an I ividual Sewage Disposal System-
......
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
p ••........, .." .
— � 7-0_
DATE. ......---•.............................••-•-•-_....-•••- Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Commonwealth of Massachusetts
- iTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
278 Wianno Ave. �S
M
g
Property Address _ //,, 2
Adnan Naber ' A D 1 S V � _3
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
ran P.O.Box 763 p
Company Address ra
Centerville Ma. 02632 9
rewn City/Town State Zip Code=
(508)428-4028 S14454
Telephone Number License Number i
B. Certification f
I certify that I have personally inspected the sewage disposal system at this address a d that the
information reported below is true, accurate and complete as of the time of the inspect on. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
C
N�� _/W 3/14/2008
Inspec or's Signaturer Date
The system inspector shall submit a copy of this inspection report to the Approving Authority)(Board
of Health or bEP)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 DER. 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.
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
' Commonwealth of Massachusetts
W ' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
' 1,
Commonwealth of Massachusetts
w ' Title,5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town 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.
278 Wianno Ave.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
` Commonwealth of Massachusetts
W `Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
278 Wianno Ave.
Property Address
Adrian Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
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"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 Y2 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.
278 W ianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town 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
El El Area
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.
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
® ❑ Pumping 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?
® ElWas 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)] .
278 Wianno Ave.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's,Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007:305,000
g ( y g (gpd)): 2007:305,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 3/14/2008
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? D.,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):
278 Wianno Ave.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town 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: 10'+
feet
Comments (on condition of joints, venting,evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 15"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
---------------------------------------------------------------------------------------------------------------------------
Dimensions: 1500
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W ° Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is Osteryille 02655 Ma. 3/14/2008
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.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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.):
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):
278 Wianno Ave.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
` Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cwM 278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is Osterville 02655 Ma. 3/14/2008
required for
every page. City/Town 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.):
t
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box id Ievel.Box has 2 outlet laterals with equal distribution.No evidence of solids carryover.No signs
of leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osteryille 02655 Ma. 3/14/2008
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: 2-1000.gallon
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Pit#1 water was 5'to invert stain line 42"to invert.Pit#2
water was 50"to invert and stain line 40"to invert.
278 Wianno Ave.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
278 Wianno Ave.
Property Address
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
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.):
278 Wianno Ave.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Map Page 1 of 2
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f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
278 Wianno Ave.
Property Address .
Adnan Naber
Owner Owner's Name
information is required for Osterville 02655 Ma. 3/14/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LPs 18'
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:
As-Built Card.
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
278 Wianno Ave.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
' r
Town of Barnstable
oFTM
Regulatory Services
saxivsresie Thomas F. Geiler,Director
SM6
a3s9.
pTEp Mp`l p
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-8624644 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
not 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.
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9/14/01
DATE' ;-------- -- -
f 275 Wianno Ave
y P R 0 P E R T Y A O O R E S S; _,_„ „--_.,, ,.,.;.,,.——
Osterville1Mass_____ >�h— , �
-- - --
On rho abo,Yo dale, I inapoolod the eopllo ,oya:tQ'M. al, the aboyo addra s s
Thls ay3lom conalsla of (,he f lInInsl
1 . 1 -1500 gallon septic tank.
2 . 2-1000 gallon precast leaching pits. 6 'X10 ' RECEIVED
3 . 1 -Distribution box.
Baled on my Inspection, I oorlily the following oondllloaGT 0.9 2001
4 . This is a title five septic system. -( '78 Code ) TOWN OFBARNSTABLE:
5. The septic system is in proper working order HEALTHOEPT.
.at the present time.
6. #1 pit Waste water is 48." below- the invert.
#2 pit Waste water is 65 below the invert
4% .1 2
Name : _
Company; Jo, •p?,_P . _N•comb.r^b Son , rnc ,
Addre � 3 box- 66„----
-- Canc-olY111aL Ne , 07637-0066
3
TmO CCAT1fICATIOH 00e9' HOY COHeTITVTe A OVARAKTY 'OR ,WARAANTY
JOSEPH P; MACOMBER & SON, 'INC,
T+nki-Qii pooli.L9ichlleld+
pvmp:d 4 In�1+Il�d
Town 3iwir Connllallon)
P.O. Box 66 CtnlirYllli, MA 02637-0060
775-3))0 77$4412
h 1
,per L.
COMMONWEALTH OF MA.SSACHUSIETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL'PROTECTION
TITLE 5 Y
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION a
Property Address: 278 Wianno Ave
Osterville,Mass.
Owner's Name:Dayid Derosier
Owner's Address: Same
Date of inspection:
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc ;
Mailing Address: P.O_ Box 66
rpnf-er�,; i l a 14a 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT -
I certify that l have personally inspected the sewage disposal system at this address and that the information reported
below is rrue, 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:
L/j/Passes
Conditionally Passes
_ Needs Further Evaluation by the Local,Approving Authority
Fa, s J
Inspector's Signature Date:
The system inspector sha ubmit 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
f.',"This report only describes conditions at the time of Inspection and under the conditions of use at that
�trtne. This inspection does not address how the system will perform in the future under the same or different r
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
F Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 278 Wianno Ave
Ostervi e,Mass.
Owner: David derosier ,
Date of Inspection: 9 1 3 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. 6-stem Passes '
I have not found an information hich 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: __ J
The septic system is in ,proper working order
at the present time
B. System Conditionally Passes:
Aga 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
distribution box is leveled or replaced
ND explain:
The system required pumping more than-4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND'explain;
2 ,
Page 3of11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) '
Property Address: 278 Wianno Ave, ,
usterviiie,MUNT.
Owner: David erosier
Date of Inspection:
C. Further Evaluation is Required by the Board of Health: '
Conditions exist which require ftu-ther evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. 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:
itO 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:
A� 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,
&�o The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
40 The system has a septic tank and SAS and the SAS is within 50 feet of a.private water supply well.
:� he system has a septic tank and SAS and the SAS is less than 109 feet but 50 feet or more from a
private water supply well". Method used to determine distance l_galp�
"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: 278 Wianno Ave-". ..
Osterville,Mass.
Owner: David Derosier
Date of Inspection: 9/13/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the�Tollowing for all inspections:
Yes N
_ ackup 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
lclogged SAS or cesspool
—/ Static liquid level in Wie distrit�ution box above outlet invert due to an overloaded or.clogged SAS or
cesspool / r}
.,
�1 iquid depth-in�cesspeel is less than %6"below invert or available volume is less than day flow.
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
Hof times pumped
_ �/�y portion of the SAS,cesspool or privy is below high ground water elevation.
t/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.
portion of a cesspool or privy is within 50 feet of a private water supply well.
_,2 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.)
,(f (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.
l
E. Large Systems:
To be considered a large system the system must serve a facility with's design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes'or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes now
it 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(I.nterim Wellhead Protection Area—IWPA)or a mapped
Zone II of a.public water supply well
'If you have answered"yes"to any questionin Section E the system is considered a significant threat,or answered~
"yes" in Section.D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department:
4 �» T
r
Page 5 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 278 Wianno Ave .
s ervi e,Mass
Owner: David Derosier
Date of Inspection: 9 1 3 01 ,
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
_ 4/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; eluding the SAS, located on site?
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the ffles 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))
Page 6 of 1 1
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM-
PART C
SYSTEM INFORMATION
Property Address: 2�8 Wianno Ave.
Osterville,Mass. _
Owner: David Derosier
Date of Inspection: 9 13 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CNIR 15.203 (for example: l 10 gpd x# of bedrooms): .��il1Q °,i rs'd 64
Number of current residents:
Does residence have a garbage grinder(yes or no): .G�
Is laundry on a separate sewage system,( es'or no):A-8 [if yes separate inspection required]
Laundry system inspected Syeess or no):
Seasonal use: (yes or no): J
Water meter readings, if available(last 2 years usage(gpd)):
Sump Pump(yes or no): o J
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL A.
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):�l9
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no)`.
Water meter readings, if available:
Last date of occupancy/use: A111 .
OTHER(describe):
GENERAL INFORMATION
Pumping Records c AZ4
Source of information: 19 ,FO
Was system pumped as part of the inspectiori.(yes or no): 066
If yes, volume pumped:_�gallont - How was quantity pumped determined? /f
Reason for pumping:
TY"F SYSTEM x
ASeptic tank,distribution box,soil absorption system
4�Single cesspool
Overflow cesspool
ZOPrivy
Shared system(yes or no)(if yes,attach previous inspection records, if any) "
42 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): 6,77
Approx' ate age of all comp,n ts, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6 ,
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 278 Wianno Ave
Os ervi e,Mass.
Owner:David Derosier
Date of Inspection: 9 13 01
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of consmiction:,f/' ast iron _Y40 PVC,</-Jothtj(explain):
Distance from private.water supply well or suction line: !dam
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tiaht.No evidence of lPakag -_Th6 system, is
vented through the house vents.
SEPTIC TANK: Zlocate on site plan)sti7,01
Depth below grade:
,.
Material of construction: _concrete,,4Dm eta l,LbfiberglasS4.p olyethylene
-419 other(explain) Ajf
If tank is metal list age:Vd Is age confirmed by a Certificate of Compliance(yes-or no):1tV(attach a copy of
certificate)
Dimensions:
Sludge depth: .i?t
Distance from top o udge to bottom of outlet tee or baffle:re-
Scum thickness: J
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto of outlet^tee,or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of-leakage, etc.):
Pump the septic tank every 2-3Inlet & outlet tees are
in place.The tank is structurally sound and shows no
evidence of leakage.
GREASE TRA$(�blocate'on site plan)
Depth below grade:-/1
Material of construction s!/4concrete4).4 metal�P fiberglass.�olyethylened&other
(explain): 160
Dimensions: 60
Scum thickness:
Distance from op of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or:baffle condition, structural integrity, liquid levels,
as related to outlet invert, evidence of leakage, etc.): a
Grease trap is not present.
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 278 Wianno Ave *�
s ervi e,
Owner: David Deros�er
Date of Inspection: V 1 3 V I—
TIGHT or HOLDING TANKI Vf (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:.4)�—
Material of cons tructiog: concrete4& metal tI4 fiberglass.j�polyethylene. other(explain);
1 Dimensions. J
Capacity: allons
Design Flow: 0 gallons/day.. - J
Alarm present(yes or no): 4,0 '
Alarm level:—j Alarm in working order(yes or no):
Date of last pumping: AZ4
Comments (condition of alarm and float switches, etc. :
holdingtanks are not present
DISTRIBUTION BOX: (if present must be opened)(locate on,site plan)
•) I
Depth of liquid level above outlet invert: .GGb ,
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of °
leakage into or out of box, etc.):
Distribution box has two laterals.No evidence of solids
carry over.No evidence o
PUMP CHAMBEFkLa e(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is notp—resent.
"
_ a 8 '
k
Page 9 of 1 1
1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
4 PART C
SYSTEM INFORMATION(continued)
Property Address:278 Wiahno Ave
Osterville,Mass.
Owner: David Derosier
Date of Inspection: 9/13/01
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
2-LP-1000 ' s Packed in stone. 6 'X10 '
If SAS not located explain why:
Located
Type
;Teaching pits, number.
Teaching chambers, number:
4)2) leaching galleries,number:
leaching trenches,number, length: d
-.14 leaching fields,number, dime sions: O
.(>yoverflow cesspool, number:
,0z) innovative/altemative system Type/name of technology:rj71-e, X7& C 29 amtlg
Comments (note condition of soil„ signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to medium sand to fine sand.No signs of hdraulic
failure or Dondincr Soils are dry Vegetation is normal
CESSPOOLSLI?cl4 (cesspool must be pum?ed as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: 414
Depth of solids layer:
Depth of scum laver: �fiQ
Dimensions of cesspool: 441
Materials of construction:
Indication of goundwater inflow(yes or no): AA15
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,,etc.):
Cesspools are not present.
PRIVY.L;?dti (locate on site plan)
Materials of construction:
Dimensions: /f
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy is not ,-present.
Page 10 of I 1 a 0. 4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
Property Address: 278 Wianno Ave
s ervi e,Mass
Owner: David Derosier.
Date of Inspection: 9 1 3 01
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.
fi
. 10
Page l l of l l
t
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 278 Wianno Ave
s ervi e, ass.
Owner: David erosier
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar `
Shallow wells
Estimated depth to ground water feet
z
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)
_ Checked with local Board of Health-explain:
_Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
RPCJ, ahem R Madel Grond water ab: ye -::Qa 1 eyel
LJSPd itSC'S 92 OQOI Plate 7 Annii;;l Ranges Of nrnrincl wate_-
i1sPr1; riRr—S ohaarizatinn Well data fo-r 11jnQ 1992
Top of Ground
Leaching
Pit . ;eel
Feet Below Bottom of Pit
i ,
,Groundwater: - _
Therefore, the vertical separation distance between the botto
Of the leaching pit and the adjusted groundwater table is
feet.
11
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1 TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D. - CERTIFICATION
,.,,,,, '
-TYPE OR PRINT CLEARLY.- - ,
PI?OPERTY INSPECTED 278 Wianno- Ave Osterville,Mass.
STREET ADDRESS 278 Wianno Ave '
ASSESSORS MAP , BLOCK AND PARCEL # 140-130
OWNER' s NAME David Derosier
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME -Joseph P.. Macomber & S.an Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
Strevt Town or City Stat• IIP
•COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 _ 1 578
CERTIFICATION STATEMENT Y
I certify that .I have personally inspected the sewage ,disposa7 system at
this address and that , the information reported is true , accurate , and
omplete as of the time . of ,inspection , The inspection was performed and any
recommendations regarding upgrade, maintenance, and repair are consistent
with my training and experience in the proper functioTi -and maintenance of on-
site sewage disposal systems .
Check ne :
System PASSED- / �
The inspection «hich I have conducted has not found any .information
which indicates tliat the system fails to adequate�l,v protect public
health or Lhe environment as defined in 310 CMR 16 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con ilcted has found � that`, the system fails to
Protect the public health and the environment in accordance with Title
6 , .310 CMR 15'.303 and as' specifically noted on PART C - FAILURE
CRITERIA of . this inspection orm ,
-
Inspector, Signature s- Date ll
ecopy of this c ification must be provided to the OWNER, the BUYER
On
Where applicable ) and the DOARD OF HHALZ'iI,
* If the inspection FAILED,- the owner or operator shall upgrade ' the , eyetem
within one year of the date of the inspection , .unless allowed or required
,otherwise as provided in 3.10 CMR 16 . 305 ,
partd .doc
CONINIONWEALTH OF NLASSACHt•SETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR
DEPARTMENT OF EN-VIRONNIE\TAL PROTECTION r
ONE WINTER STREET. BOSTON. AtA 02106 Fl?-.Se•EeOG
• .. x MAY. 1 1ggQQ
WILLIAM F.WELDrowNOF 1'rr
RA,N%T- : HEALTH pEPT.�IE
Govcniz- _.:
ARGEO PALL CELLCCCI
. DA 'TRL'l
LL Gavataor ' SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM^•; 1. �mmissior
�P PART A -.-
CERTIFICATION
LoT rs000 ►�,�,h, _ .
Property Address; W U Vi_I C6T'tCU Vtl, ` Address of Owner. .
g :Of difierentlDate of Inspection: LA'L\ 4
Name of Inspector. E� Cn - CtiQ.hb���1�'1s4
I am a DEP ap roved system inspector pursuant to Sec'tion'13.340 of Title S C310 CMR 13.000)
Company Name: ��a r��a'e EA ter,a, A-g
Mailing Address: 2 o AenA e-32F CA . H d75Z&ep5L H r77,p 2-tC4 7
Telephone Number: rSe-,e-1 CcL;•q— /L,c Zo
CERTIFICATION STATEMENT
I cer:iN'that I have pe•sonally inspected the sewage d!srosal systern a: this address and that the inrormation reported,be:cw is true, accurate
and comolete as of the time of inspec:-o-. The inspec::an was pe^ormed'baset: on my training and,experience in the proper funcic- and
maintenance of on-site sewage disposa; systems. The mwlr:
Passe: ,
_ Concit-onaii\ Passes
_ IsEeci Furthe- Evaluatlom Sy the Local Aprro.rng Authorm
Fa. :
Inspector's Signature: Date: 2.
T:ie Svi:e-r Inszezo• sha'' submu a copy of this inspec:,on retie.; to the Aperoving Authorm- within thud- (30i days of completing this
inspection. It the system is a shape: .vstem a- ha- a ce-Sn floes• of 10.000 gDd or greater, the inspee cr and the sysre•r. owner shall submit
the repo-i to the a.-oropnate revor21 office of the Oeparment of Envirenmenta* Frotec:ior.. The crig:na! should be sent cc the,systern owne
and copies :--i; to the buyer, if applicable. and the approving authorin
INSPECT10% SUMMARY: Check A, E, C, or D
Al SYSTEM PASSES:. : :.
I have not found any information which indicates that the system violates any of the°failure Criteria as defined in 310 C.MR 15.303.
Any failure criteria not evaluated are indicate✓ below..
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
_ F
One or more system components:as described-in the 'Conditional Pass' section need to be replaced or repaired. The systern, upe
completion.of the replacement or repair,.as approved by the Board of Health, will pass
Indicate yes, no. or not determined (Y. N. or NO,. Describe basis of determination in all instances. If'not determine?-, explain why not.,
s The septic tank is metal, unless the owner or operator has provided the pec PY system ins .or with a co of a Certifiiote of
Y
Compliance (attachedi indicating that the tank was installed within twenty (201 years prior to the date of the inspection; c .
the septic tank, whether or not metal, is cracked, structurally unsound, shows subsontial infiltration or exfiltraticn, or tani
failure is imminent. The system will pass inspe^,ion if the existing septic tank is replaced with a conforming septic wk
as approved by the Board of Health.
SUBSLRFACE,'SEWACE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ,
Owner:
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES tcontinu?-: '
Sewage backup or'breakout or high static water level observed in the distribution box,is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will"pass inspection if(with approval of the
Board of Health). Descnbe observations:
broken pipe(s) are replaced .
obstruction is removed a
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipesl..The system will pass
msoection if twith approval of the Board of Health):
broken pipesr are replace:
obstruction is removed h
•
CI FURTHER EVALUATION IS REQUIRED BY THE.BOARD OF HE+ILTH: "
Conditions exist which require furthe•evaluation by'the Board of Health in order to determine if the system is-failing to protect tl^
public health, saie:�•and the environmertt.,
1l SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH A►rD SAFETY AND
;THE ENVIRONMENT:
Cesspool or prnti is within 50 ie-t of a surface water
Cesspoo'. or pri%-v is within 50 fee: of a bordering vegeated wetland or a salt.rnarsh.,
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFtcilf ASO THE
ENVIRONMENT:
The svitern has a septic tank and soil absorption system (SAS, and the SAS is within 100 fe-:'to a surface water supply c
tributary to a surface water supoly. `
The system has a septic tank and sail absorption system and the`SAS is within a Zone I of i,public water supaiv well.
The syste-n has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system+ has a septic tan_k and sail absorption systern and the SAS is less than 100 fee, but SO fee: or more from a
pri'ate water supply well, uniess a we(1 water analysis-for•colifcrm bacteria and volatile organic compounds indicates th
the well is free from pollution from that'faciiity and the presence of ammonia nitrogen and nitrate nitrogen is equal to k
less than S ppm. Method used to determine distance (approximation not valid).
3) . OTHER
Page 2 o1 t0
SUBSURFACE SE"AGE DISPOSAL SYSTEM INSPECTION' FORM
PART A
CERTIFICATION (continued)
Propertv Address:
Owner: _.
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either "Yes` or "No' as to each of the following
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
-
the failure.
Yes No
Backup of sewage into facile or system'component due to an overloaded or clogged 5A5 or'cesspool.
Discharge or ponding of effluent to the surface of the ground,or.surface waters due'to an overloaded or clogged SA5 or
cesspool.
Sta:ic !iauid level in the distribition box above outlet invert.due to an.overloade.d'or clogged 5A,5 or cesspoo:.
Liouid depth in cesspool is less than 6" below invert or available volume is less than 1/2�dav fide•:
c
Recuired pumping more that 4 times in the last year NOT due to clogged or obstructeo.pipes .
Number o`,times pumped _
t
An%- portion of the So:l Aosorption System, cesspool orrpriv)• is below the high groundwate• eievanor:
Am por:on o'a cesspool or prnti: is wnhir, 100 feet of a surface water supply or tributan• to a surface water supply-
- And por ion of a cesspoo' or prn,�• is within a Zone.I of a public well.
Am pc^.to-• o:a cesspool.or pri%ti• is within 50 feet of a private water supph well
Am•por,.or. o'a Cesspool or privy is less than 100 feet but greater than 50 fee: from.a private water supph• well with no
acceo:able water qualtt` analysis. If the well has been analyzed to be acceotabie, attach copv-of well water analysis for
coliforrr, bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes` or "No- as to each of the following.
The foliowir.g Criteria app;% to :arge systems in addition to the criteria above`
The system serves a iacilin with a design flow of 10,000 gpd`or greater (Large System; and the system is a significant threat to
public hea!th and safety and the;environment because one or more of the following conditions exist.
Yes No .
y drinking water supply
— — K
the system is within 400 feet of:a surface dri
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 1l'of a .
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater:treatment program -
requirements of 314 CrvtR 3.00 and 6.00. Please consult the local regional office of the Department for-further.iniormatiocti�--
(r.v&sed 04/25/91) Page 3 of 10 #
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addeess: u�1 U �►.�i�-1ai-�C� �V�..,
Owner:%N�(y,V
Date of Inspection:U l`V�%
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ygs No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system'has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
kAs bull, plans have been ootained and examined. Note if they are not available with N1A.
The fac:hn or d%•elling was inspected fof signs o-sewage back-up.
_ The system does not receive non-sanitan. or industrial waste flow.
The site %as inspected for signs of breakout:
— All system.. component_. excluding the Soil Aosorption System,, have been located on the site.
)( — The septic tank manho;e� %ere uncovered. opened. and the interior of the septic tank was inspected for condition of
baffies or tees. materia; o• construction. dimensions, deptn of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on
-
The o The fac.li �.ne• .ano occupants. tf cliheren: from owneri were provided with information on the proper maintenance of
Sub•Sunace Disposal 5vsterr..
+4A Existing iniormation. Ex Plan at B.O H. '
_x1 — Determined in the field of an% ofahe failure criteria related to Part C is at issue,.appr6ximation of distance is
-`` unaccez)tabie (15-302:31:b0
f
z. •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
C SYSTEM INFORMATION
Properts Address: �(� ��U NNCj t
Owner:_Q,v_ostti
Date of Ihspeclion: Z�Q Q
FLOW CONDITION'S
RESIDENTIAL:
Design iloN '55C e.o-d.lbedroom for S.q'S
Number of becrooms 015
Number o.current residents
Garbage g•: der (yes or no!:
Laundry cor•^ected to system (yes or no!
Seasonal use ryes or no::�
Water meter readings. if available (last two (2 year usage igpdi: 1J
Sump Pump Ives or nor N
Lai: date o occupancy NT
COMMERCi4L'INDL'STRIAL:
Type of establishment
Design fio\% _�ahonslda\
Grease trap present ryes or no_
Industna! haste Holding Tani: present. Ives or no
:on-sancta,\ waste d-scnargec to the T!tie s\•stem ;yes o7 no"
\%ater meter readings if availabie
Las:pate os o c.�;,znc,
i
OTHER: .De:cnbe
Last pate of occuoanc.
GENERAL INFORMATION' '
PUMPING RECORDS and source of information.
- ��tiM,acJl y Min, ,DLtoV
System pumper as par, of inspeeion. tees or no._JS.►r')
If yes, volume pumped eallons
ReasonJor pumping -
TYPE OF SYSTEM
Septic tank/distribution boxrsotl absorption system
Single cesspool
CNenlow cesspool
Shared system (yes or no) (if yes, attach previous inspection records, if any) -
I/A Technologv etc. Copy of.up to date contract?
Other - -- -
APPROXIMATE AGE of all components, date installed (if known) and source of information: }
Sewage odors detected when arriving at the srte.'(yes or not _. ..._
(revised 04/25/91)
Page 5 of 10
r _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
G SYSTE.I&INFORMATIOti (continued)
Property Address: ��`j (1J t P�NN t
Owner: Qee�St'Z
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade.
Material of construction. cast iron 40 PVC _other (explain)
Distance from private water supply well or suction Ii-
Dtameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:t5
(locate on site plan
Depth below grade
material oi construction- �con re:e -- me:a _Froer iass —Polyethvlene _othertex lam'
If tank is me-.a;. Ifs: are _ Is age con:irrnec c� Ce^.fica.e of Compuance _(1•es-No,
Dimensions A�
Sludge depth 1w
Disiance from top o: siudee to boron of ou:;e: tee o• ba-::e 3D f
Scum thickness- nu _
Distance from top of scum to top o'outle: tee or bake_ (o it
Distance from bottom of scurn to born-: o;outte: tee e• bar.e
Now dimensions were determined �1�4o.Iut�
e Comments
trecommendation for pumping. condition o� iniet and outlet te=s or,baffles. depth of liquid level to r ation to outlet invert, structur I
integrity. evidence of leakage, e:c.t Um I Sf
�e!
T t
GREASE TRAP
(locate on site plan;
Depth below grade:
Material of construction: —concrete _metal Fiberglass _Polyethylene —Other(explain)
Dimensions: -
Scum thickness: -
Distance from top of scum to top of outlet tee or baffle. -
Distance from bottom of scum to bottom of outlet.tee or bafiie:
Date of last pumping:
Comments:
(recommendation for pumping, condition of im,let,and outlet tees or baffles, depth of liquid level in relation-te-outiet4nvert;structural---- - —-
integrity, evidence of leakage. etc.; ' - "
Fq.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION (continued)
Propem Address:
O%ner:
�ts��
Date of Inspection: �2�Q
TIGHT OR HOLDING TANK:—K-1 .lank must be pumped prior to, or at time, of inspecttont
(locate on size plan,
Depth below grade.
Material of construction. concrete metal Fiberglass _Polyethylene -other(explain)
N ,
Dimensions:
Capacrn gallons
Design floes galtons"da.
Alarm level Alarm to %korking orde! _ Yes. _ ►o
Date of previous pumping
Comments
(condition of inlet tee. condition o- a!a,n- and float switches. etc.)
DISTRIBUTION BOX:
iloca;e on site p:a-
Death o'. liouid le%e' a00%e oune: in�e" u-��O�ZZzTZN1 s
Comment
mote ti lee! and d�str�but on is a ua' e�idence of solids tarn over, e� nce leak tn oro tit of boa. e!c.l
TQ��. C�0.�F�yf B�I.raP T Lonl�o�nlI
PUMP CHAMBER:-9-1>
(locate on site plan.
Pumps in working order: (Yes or No'
Alarms in working order (Yes or No
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/29197) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit
r -PART C
SYSTEM,INFORMATION (continued)
Propert? Addr-is:
Owner:
Date of Inspection: `
SOIL ABSORPTION SYSTEM (SAS):
(locate on site a' ,.plan, if e exca.a;�on not r wired but ma be a roximated bn n-(n rusry 'm th
If not determined to be present, explain:
Type:
leaching pits. number. loh,(o
leaching chambers. number._
leaching galleries, number.
leaching trenches. number,length:
leaching fields, number, d.me•sion.s
overflow cesspool, numbe-
Alternative system y
Name f T nn i v a e o ec o og
Comments
n n f
� ote condrtiq o soii, s! r.s of hydraulic failure. leve` of ondin . c�nd�ti of vegetation. et i
g P g g �.
h
CESSPOOLS:
(locate on site plan.
Number and configura:.or
Depth-top of liquid to inlet irtver,
Depth of solids lave-
Depth of scum laver
Dimensions of cesspoo: `
Materials of constructioc }
Indication of ground ate
inflow tcesspool must pe pumpec as par, of inspectron}
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: e
(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.): - -
(rava ud 0�/2S/97)- - Page a of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GG SYSTEM INFORMATION (continued
PropertN Address: p17Cj LlU1i#"- ,J"C) .
Owner: tQ,O��Q .
Date of In,pectionc
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reverences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house(
C. a�1�
• A
Iss-ab '°
- -- H.q• f of 10 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
G SYSTEM INFORMATION (continued)
Proper . Addrei-X i> Lmet -0 .
Owner ie&so(— M.
Date of Inspection:
Li09&
Depth to Groundwater Feet ;
Please indicate all the methods used to determine High Groundwater Elevation:.
Obtained irom Design Plans on record
Observation o;Site (Abuning property. observation hole, basement sump etc.)
Determine it from local conditions
Cnec: %%ith local Board o• neaar
Chec: F-.NiA Macs
Chec�. pumping records
Check loca! e--ca%a:o•s ins:alle•s
Lse Da'a
r.
Describe in cx o, v-xcn: ro•.% %o_ es:ao?-shec the Cround"%xe• Elevation (Must be compie!ed
�,5, �oeyL�-�1 ��s`�'�"( 1, � la°�IG �UV.e.g���,�Qrf�•;� -�-i �� �oQZ.
Y �
(r..vC..� :i::'_•9" .. Page 10 of 10 -
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