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0134 WINDSWEPT WAY - Health
E= 052 DSWEPT WAY, OSTERVILLE 04.002 1 / � 11 k n rl6'3G? Town of Barnstable P# D ga'tt,'men. of Health,Safety fatdd?EEnvt en�taal*Sterj�;i � 1, Publie-.Mteau D'iii'ii"on " . Date: ' 367 Main Street,IIy,F rnis MA`02601' MA89. 'F� 'east . Time o M Fee Pd. rEm►n�+1. bate Scheduled G . r+ �'®al �' atabil Assess Gent f®r Sera 'e Dis o;sal - r t t Witnessed B :. �� Performed By: �1l CD Tt Location Address w'nds� t Owner's Name Max rLe ! D ,, �� ti rAddlressi. •�•f -,#$ I .q Assessor's Mapfflgcel: _OZ Engineer's Name „` e NEW CONSTRUCTION REPAIR Telephone J`^U�"J J WY f a q Land Use �II��SiC J��i( Slopes(%) C�/� Surface Stones ft Drinking Water Well CtiC/ ft -- Distances from: Open;Water Body ft Possible Wee Area g Ei(SQ f ft Property Line Other ft - Drainage Way P Y SKETCH:(Street name,dimensions of ot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) 5 s I ,, 3 Parent material(geologic) il/ IV�+4 r Depth to Bedrock zr^� + n Depth to Groundwater: Standing Water•ln Hose: Weeig�from Pit Face P_ Estimated Seasonal High Groundwater_ .............:..::.........:...::.:........;....:..:. Method Used: 1`16 De in. th.toosflwmottles: in. Depth Observed standing in obs.hale: P. �Depth to weeping from side of obs..hole: in. Groundwater Adjustment ft. index Well#___._._ •Reading Date:_.___ Index Well level __' AQj4lfactor " "' Adj:Groundwater Level __ �D Ion-:::::.� ...............................................:........................................,...................... :............... w Observation Time.at9{;,, �.. ,.a. .. .., Hole# V. Depth of Pere (Ot�r/ Time ae6 t Start Pre-soak Time(a3 ��J Time,(9"-6")M ►sa End Pre-soak /Of Rate Min./Inch ,/Zwtd 7''ea, Site"Suitability•Assessment: 'Site Passed-•mil •r Site Failed, Additioi�al�Tes�ting,Needed(Y/N) .. " i; e•,...L.'Y}+ ,sh -i.z, i�t`•: 1 isx` ' = A Original: Public Health Division Observation Hole Data'l'o l$e�.ompleted on`Bacic Copy: Applicant �. 44 :...:. :i :.: ; ::::::<.:.:;:.::•;;:.;;;:.:::::.�:::.;: ar t. .E. .11Soil;'Color'tr t. SoslOthe .Obptli from Soil Horizon Soil Tez'lure Munsell _ Mottling (Structure,Stones,Boulderes. :Surface(in.) (USDA). ( ) ° It IAVIZ .w .; t4� • y er«3 iT •_ t>± .y�3j ,���.� 6 �rr� r i;yt y� gp Depth from Soil Honzon Soil Texture Soil Color Soil w '=, ,,_ Other ..`Surface(in.) (USDA.) (Munsell) Mottling (Structure,Stones,Boulderes. o n °°Gravel) UL ';i oriz:on»>::>:;:::><>»:Soil.;:;,.;;:•;:.;:.;:•:;::;:::::•:;::::::::....................... her Depth from Soil Horizon Soil Texture S�11' Color Soil t Surface(in.) (USDA) nsell) Mottling (Structure;Stones..Boulderes. o sistcngy.°o Gr el Depth from Soil Horizon Soil Texture Soil Color Soil Other Su"dace(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. onsi en °o r e � r ' 12d--.d N4..•w. �Flood�I�nsu�'a�nce�I�a�t��lkla�n .a _ ' • A# Above 500 year floodrboundary.•.No v Yes/� ift *Ithim?500.year.boundary No Yes wiihin tao year"floodtb'oundary`No; Abpth of atural c ink P ryiaus 11laterial Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ff--:not,what,is the depth of naturally occurring pervious material? Certification b certify that on date)I Have passed the soil evaluator examination approved by the Departmenf`oflEn�"vironmeiitalTTF66tection_and,that•the'°above analysis was performed byrme.cons istent,w:ith the required.training, xpertise andyexperience described in 310 CMR 15.017. Date Signature �C/ � - L0 A u0N p SEW . PERMIT N k J G VI LADE v INSTA LLER'S NAME b ADDRESS iUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED cju 4 c_ cli 6Z - FIm of ....................... TKE COMMONWEALTH iOF MASSACHUSETT-9 BOARD OF HEALTH - -----rO-*V-AJ..............OF.......... .......................... Appliration for Uispostti Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: # 4 _2 4,41............... - ----49 --------------------------------------------------- Location-Address or Lot No. ..... 1 c2- -&Alkl------------------------------- Ow jer Addres;, ...........44 ........................... ............................ ....Z;r---/1� ....tneXATI Installer Address Type of Building Size Lot.__._ '_$---_-------!- feet _2 U Dwelling—No. of tedrooms-------------4..........................Expansion Attic Garbage Grinder �1 A4 Other—Type of Building ............................ No. of persons.__._._._._..__..__.....__.. Showers Cafeteria 04 Other fixtures ..................................................................................................................................................... Design Flow.........13.5 L-------------_----gallons per person per day. Total daily flow......A60 . . ..........................gallons. Septic Tank—Liquid capacity/5W.gallons Length................ Width-_-_----------__ Diameter....._.__...._. Depth---------------- Disposal Trench—No..................... Width......_.....___.__.. Total Length-___--_---.__-_-..- Total leaching area....................sq. f t. J; Seepage Pit No........?.......... Diameter........&.... Depth below inlet.._6........... Total leaching are,_6 18...sq. ft. Other Distribution box ( ) ---- Dosing tank ( ) 7 Percolation Test Results Performed by---------AL A/d....A h L/z?,v.,c 6-----PA.1 Date------ell-to/ ------------------ Test Pit No. 1... minutes per inch Depth of Test Pit----- -------- Depth to.,ground water----- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_---_-_____-.-_--.-_. -----/ ....................�.................................................... --- ------ O Description z r ------eZe a_e-,.Y A.&_7�.....Qf Soil.........&.Z...... .............e.r...... ----------- ----------------------------------------------------- ....................................................................... U W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ .............. ..............Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t board of health. Signed �f ...................................................... ................................ Application Approved BY . ...... -- ------------------------------------ Date Application Disapproved for the following reasons:........................................................................................1...................... .........................................................................................................I............................................................................................... Date PermitNo......................................................... Issued........................................................ Date d • No......... � 4, Fx».............................. TKE COMMONWEALTH'OF MASSACHUSETTS BOARD OF HEALTH ........................ ......._...-----.OF...................................... --•--------• --...---------------------------- , ppliratinn for Riiposa1 Worko Tonfitxnrtiou Vrrmit F" Ada Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System'at: ......................................................_.............-- ---------•--------------------•---•---...----•----•------••-•-----•---•---....------........-----.. Location-Address or Lot No. ---•------------------------•---------..-...------------------------------------------------------ .........=........................................................................................ Owner Address W .. Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms________________ __________________________Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building _________________ ------- No. of persons--________-_---_-______-___ Showers ( ) — Cafeteria ( ) Other fixtures _____________ W Design Flow........................................... per person per day. Total daily flow............................................gallons. W Septic T.nk—Liquid capacity------------gallons Length---------------- Width---------------- Diameter_---..-.__._____ Depth_---___._.------ Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No---_---_--------- Diameter---___--___.._---__- Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_____._-.-__---__. fX4 Test Pit No. 2................minutes per inch Depth of Test Pit------------------.. Depth to ground water......._.__............. ODescription of Soil------------------------------------------------------------------•----------------...--------------------------------------------------------------------------------- x W --------------------------------------------------------------------------------------•-------------------------------------------------------...........................I........................... V Nature of Repairs or Alterations—Answer when applicable---------------------------------F_....___......................__._.....___...__...._..__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State'Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by th board of health. Signed --••---------------------------------•-- ................................ D Application. Approved BY ° ---- --------------------------- ---- 1 '�Y .t - --------- Date Application Disapproved for the following reasons:................................................................................................................ s �w ------------------ Date PermitNo......................................................... Issued........................-............................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............c9' +y'" _..........OF.... ..........:...............:.......................................... T ntifiratr of TOmp aurr THIS ZS TO CER IP That the Individual Sewage Disposal .System constructed ( or Repaired ( ) bY-•-•--..•.... ------- ... .. ------------------------------------- -- -------------------------------------••------•-•---------------------------------•----•-----....----- f i- Ins r at---•-0 --- •-------- ��r - ------------------------------------------------------------------------------------------------ has been installed in accordance with the provisions of Artile XI of Y e State Sanitary Code as described in the application for Disposal Works Construction Permit No... .d ............ dated.._.._.._....______.________________.._..______. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE.....................................................g. �t �[0 Inspector-------------- 1441-------= ............................... THE COMMONWEALTH OF MASSACHUSETTS r . rr BOARD OF.,, HEALTH �/-�" ....... ..............OF..........:--- .----------------------------.....-----• d NO. ............��.. FEE........................ Permission ' ereb aranted---------_..._.........................................................3g , to Construc o Repair, an-Individual Sewage .- osa Svst- em.r. Street as shown on the application for Disposal Works Construction P No--------------------- Dat - ---- ------------------- - ----- -----------------_------............. Boa o Health DATE. 8f c /- L.....--•--------- FORM 1255 HOBBS & WARREN., 6N,C.. PUBLISHERS oil���J?k'-�.�-C�.�F2�..�r -:�.-.t L0 ATION S E W A c E P E It fAtI T �i ' LAc E _ INSTA LLER'S NAME i A.DDR.ES3 GUILDER OR OMirl ER0-01 _, I DATE PERMIT 1SSYED l l�/D — b? l ® A`TE CObIPIIANCE ISSUED _ !� _ � Wit° f - i • 't;..,' S .s'^`�s y ....`F- qg b y a^-U,,as+-_. � a: ., t--• +H'.v x wv- - �y . s<�" -t•R:5.Yy'�"�,a. R �`- w, ^ ^^� '"""'t'^ :•..� ""'�Y� �,Y �"'� ;w zv THE FOLLOWING ' - IS/ARE THE. BEST IMAGES, FROM POOR . QUALITY ORIGINAL(S) I M A/- (Y�� L DATA sessor's map.and,lot number .19,4.P Z. _L �¢ Sewage Permit number ...G..��..1.2. 8.:.......................: Permit N . . —. t o :3'7 51 House number ... ..rfi. ....................... .t....... „, ' Cash ., - / F. :(, 4 Bond TOWN: OF BAR "f ( BUILDI :SI N? lle NG inspection date ` APPLICATION :FOR PERMIT TO. : 45 a 6. date J t inspection TYPE OF. CONSTRUCTION ...::.:...:.. ..... .� date Inspection Inspection date I n,7., The undersigned hereby applies for a permit`succording to the ation...5 . ` " x- cation ...... . .,�....... f� !yA Ir?�DXZS Proposed .... .......... .. ..... ......... .................................................................... ......... ' ZoningDistrict ............ t..... ........, ...........................Fire District .......................................................................... T J _ ZI 81 Name of Owner Ali ....4./.r... �/'/.l�liC/ .H ....Address 1�..!„,W..944... Name of Builder ...k'oGE y.../...d)ArAt9_Y d)ArAt9_X........... ....440:�t... Name of Architect .ec7.Y44-AQX4.Y..A/.A4.S...415P...Address 8•I sfw1.lj/!•X.Y....Sj P....��J<%�.!S!�./i7.9,�r�.�........ Number of Rooms ...................... .......................................Foundation ......... .. GBH/G _D /f� Exterior ............... ..�r..C..0............................... .Roofing ................... �.................................................. Floors ..................... ......... Interior #..... ................. .....T Gi/............ Pit Yd/L; Plumbin / e5f� Tl� s Heating h ...... r........................... ............... ... g ....... . •... use .................`.�.ye.. .......... .. �..8...51. C�O U. -°'. :':::...Approximate Cost Definitive Plan Approved by Planning Board :____-____—_____—-----------19 Area Srl4� / 5 O '} �j��' Diagram of Lot and Building with Dimensions ¢ AG Fee .: !. ........... ............. SUBJECT TO APPROVAL OF BOARD OF HEALTH x h� ,fib 1 j ��'�<�TAR Y C d✓A Y !\6 3 5 Z SYsT�M r ✓ } ry 4' V Q Ale Q I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. f Name . ... i cam-- cx cam_ . /' -1 .- , ,.. : 2!,�.,���...!w�,- ��w 4.. , �!°' ,�; � - �F � r ", 4 ti J a. 3{fit v •'�- .. K ry f 3 F� - f -�. 'iF )�„ } 1 i _� tty if '�' N f 5N f fN.Utz , iY M ., : l' i - Fr4- .:.yu Z. .y fi 3 1 f �t� .S"} r Y'r]W ..e r ,t �� r Vm-. , •` .rr} .,�i..t u! h i .a y M �1. �,. 9 >'u.Wr IV,,L.. y•. r �n * k .S t.Y ems- I. - - y r 5 wy d"t: .4 c fir �' ' �.-a - - i -� t „� " . * `} .ts- 7 u*`� 1p-- ,xy�.,A.�- �H �ta,, .c z ri . — 3r k a ds tr1a 9� i✓. r';f .F ,ix 4 i�i- ";KF r '`r-•c, ,,.( e� .y E.. d r { .''x if,1 , -S ,t_ .s yf'.- >.i..z c Y k `�' s ,F' u`t p bt�a M 7- '�,,, rd 3? f •p�. ) t j y" at.. •t � .1, y do 't. 6s �s}s-i,,,x a ti • -+. x �, _i- -- ♦ < L ... ++.ford W- '�1 t y a`, : P s r - c Y f : .. - . . , '. ..': ,.-�:.-.-....".,iI-...-,-,,�.�-;'-..,,A t.----.4,,.�.-.1/..,.%,).._:.-,,..,-,�..i�1�.".�..,,,,,-I�.:.--�,,I..,��,-�...,-;7� i p r .�c .r. I,-F a °+r y �_n r i •�'` 4 tom-tt�'+t' e. . ' "` '1 -�. 5 —;-..-.�r'�-A.���,--..,-,;-.,I.,.-N..-- .. :.` i wr,�. z r- r- �' ' @ , _ y 1 Vj1 r �{ y _ {r i a P, r f .ff�" k' : gat t: . - �: M r: `r f f.t r.,. 4` e r-. ! w Rd §- a,f'S °A,fi, ,,r "-.I ^ �y f•+.. c,1. ,t ; .: y 1 -oi-..` f ;�'+tiKq; 1'- +5,.t j an 's�PzML{r ,, _ - d..4 q * ,?'x c - ^...,..ram �'. ..:/ t .;. r A.. , . _ .. .:, _ .-.: -s _.;: „ .. � ,> , :i - yr ' sKj} Y A ...... _'-__-. r .h i __:__ ._... __ g s t . z F t. 3 ., f ✓ - - - . .— .. . - - $ , a, . . . . .� .. . .. . .- .. _;:_i . OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. / ? a I. Name . c-c`? .., .... . 't.`.':::. ................. ... f, Construction Supervisor's License .C..1:. : �................ . - • .1 .-. - '71- L0 ATION SEWAGE PERMITaxil N o o i. VILLAGE , INSTA LLERIS^ NAME b ADD RItSS a GUILDER OR OWNER DAl E P IRAfIT I S S U E D _ - r DATE COMPLIANCE ISSUED TOWN OF BARNSTABLE LOC 4'."ION''1,� Li LJ�r�+�sw e!�►W q SEWAGE# 50 e C w VILLAGE ©S 1 ew,1i c ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO.":B l t. L1,aR SEPTIC TANK CAPACITY � ov vC �.� LEACHING FACILI`Y: (type) 75 (size) c�- 6 X 8 NO.OF BEDROOMS 3 BUILDER OR OWNER r% 11�V►ll PERMITDATE: COMPLIANCE PATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �B<Sr 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 fee of leaching f1' ) — . Feet Furnished by � ? /ZL%�' 9.0 f CA r ..y COMMON ArEALTH OF MASSACHUSETTS '1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION •,,y See ., TITLE 5 OFFICIAL INSPECTION.FORM.-NOT. FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: od Owner's Name: Owner's Address: Date of Inspection: /> , D Name of Inspector: please print - Company Name. Mailing Address:" Telephone Number: SOC-`7'"7/ 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fs Inspector's Signature: Date: The system inspector shall suLit 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 . 6/15/20.00 page 1 Page 2 of I 1 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL<SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ' t, w Owner:. . �: �[ �! Date of.lnspection: Inspection Summary: Check A,B,C,D,.or E1 ALWAYS complete all of Section D' A. System Passes: I have not found any information which indicates that any of the failure criteria-described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below. Comments: B: System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or , repaired. The system,upon completion of the replacement or repair; as approved,by the Board of Health;will pass. Answer yes,no or not 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 exfiltratiori or tanl: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 boz. Sys' ein will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is-rem'oved distribution box is leveled orreplaced 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 pipes)are replaced _ obstruction is removed . ND explain: 2 Page 3 of I I. OFFICIAL INSPECTION:FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:. A Owner. Date of Inspection: C. Further Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health inorder 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 aseptic 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 I of a public water supply. The system has a septic tank and SAS and the.SAS is,within 50 feet of a private water supply well _ The system has a septic tank and SAS and the SAS is less than 100 feet.but 50 feet or more from.a. private water,supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified.laboratory, for coliform bacteria 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: L Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. A_ CERTIFICATION(continued) Property Address: Owner: ' _ `' �"3© Date of Inspection= (azal D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nq/ _ -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 Aistribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times_pumped /Any portion of the SAS,cesspool or privy is below high ground water elevation. J Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply.., - _ Anyportion of a cesspool or privy is within a Zone 1 of a public well. �Anyportion Any portion of a cesspool or privy is within 50 feet of a private water supply well. of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5.,ppm,provided-that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] ® (Yes/No.)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.'The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E. 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ — the system is within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is:located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "Yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system..in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 � 1 Page 5 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: S< 4 . Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes �Pdo 1✓— 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? _lC_ Were as built plans of the system obtained and examined?(If they were not available note,as N/A) V" — 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 V •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? —Y 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 R •xisting information. For example,a plan.at the Board,of Health. _ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTAIZI'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION Property Address: ,/% Gt✓ r� Owner• Date of Inspection: 073 FLOW CONDITIONS RESIDENTIAL Number of bedrooms:(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.2031for example: 110 gpd x#of bedrooms):_33-6 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es or not yes separate inspection required] Laundry system inspected(yes or no)/� Seasonal use: (yes or no . Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or n Last date of occupancy; ZZJ COMMERCIAL/INDUSTRIAL.// " Type of establishment: . Design flow(based on 310 CMR 15.203): gpd ' Basis of design flow(seats/persons/sgf,dtc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records a Source of information: 'Wei /J Was system pumped as part of the i ection es or no P :) If yes,volume pumped: gallons--How was quan ►ty pumped determined? Reason for pumping: TYP&OF SYSTEM eptic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system (yes or no)(if yes, attach previou's 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): route.age of all components, 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: �a,� Owner Date of Inspections BUILDING.SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: , Comments(on condition.of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:Zconcrete_metal_fiberglass`_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: �,�✓- t> Distance from top of sludge to bottom of outlet tee.or baffle: Scum thickness: y`i—b</ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum.to bottom of outlet tee or baffle: 7 How were dimensions determined; Comments(on pumping recommen atiot and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,ev' ence of leakage,etc.): ! tS f /r s GREASE TRAP _ ocate on site plan) Depth below grade: Material of construction:._concrete_metal_fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage;etc.): Page 8 of 11 OFFICIAL.INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION'(continued) Property Address: �. ld0 a C/J�A Lt1 _Owner: . Date of Inspecttolt: TIGHT or HOLDING TANK.J/Ikatank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions.' Capacity: -gallons - Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): .Date of last pumping.- Comments-(condition of alarm and float switches, etc.): DISTRIBUTION BOX:—Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of ,,age into or out f box, etc): 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 of pumps and appurtenances, etc.): g I Page 9 of 11 OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: (/ 1 O-caner Date of Inspection: /(V/91/0 SOIL ABSORPTION SYSTEM(SAS): ate on site plan,excavation not required) If SAS not located explain why: Type'le aching pits,number: leaching chambers,numb r: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., �0 it Ae h 66-1 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 or no): Comments(note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation,etc.): PRIVY:Ar-(rocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9. Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM:INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1'3� Owner• v Date of Inspection: /0//961 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 a building. Flo (PU 10 Page l l of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet 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: i 11 Permit Number: Date: =" - Completed by: � � HIGH GROUND-WATER LEVEL COMPUTATION . z=; Site Location: Lot No. Owner: Address: ffi - A6l�O1/O�i. rD/r� J' Contractor: Address: Notes: STEP 1 Measure depth to water table / to nearest 1/10 f . ................................................ Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well...............................:.................... /AV�. OWaterdevel range zone .....................................................I I STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to .water level for index well ............................. month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth. to water level for:index well (STEP 3); and water-level zone (STEP 23) JT determine waterdevel adjustment ..........................._................................................................ STEP o Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water !/ levelat site (STEP 1) .......:...............................................:...................................................... Figure 13.—RepfDduCible computation form. r e 4 72.)IMI LIN commonwealth of Massachusetts Ott SHE Executive Office of Environmental Affairs 419,9 �— Department of ti Environmental Protection to William F.Weld �A Governor Trudy Coxe D61// 6 0 Secrelery,EOEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: i3`I W'rwsweP) Wr*1 QSYer-V,Jte Address of Owner: Date of Inspection: �Jov. d)t t 0A,5' (If different) Name of Inspector: `3"C-C Company Name, Address and Telephone Number: Sin,;-e.`i'A C��.er,,:11�,Ni�. sob-*18-ssa� CERTIFICATION STATEMENT I certify that 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: V'-Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature- Date: /��- 078 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 Printed on Recycled Paper � r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `• ' PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the p distribution box is ue to broken or obbtrt he pipe(s) or due to a broken, settled or uneven distribution box. The system will ass inspection if(with approval Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require 4urther evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HE ALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESSNING IN MANNER OF HEALTH PROTECT ERMINES THAT THE SYSTEM IS FUNCTIONING PRO CT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The wctem nas a septic tank ano soli a�sorpuon system and is within 100 feet to a surface water supply or Uibutary w a surface water supply. _ The system hay a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water ria and volatile ganic well is supply well, lution fromunless a elthatafacility ter land the ysis for cpresse ce of ammonia nitrogenrand nitratepnitr nitrogen is equalounds indicates ttotohless than 5 tree from pol ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 GMR 15.303. The basis ard of Health should be contacted to determine what will be necessary to correct for this determination is identified below. The Bo the failure. _ Backup of sewage into facility or system component due to an 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. 2 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 13y t.-r�.��s�,,�Ttvtg- Owner: Date of Inspection: D] SYSTEM FAILS (continued): jt/�14 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: I The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 13y ��osc egg Lki(N.3- Owner: Mrt- �i q. \�P�2m."�IAwN Date of Inspection: Ncx, d`r,tgSS Check if the following have been done: -ZI-Pumping information was requested of the owner, occupant, and 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. IVO As built plans have been obtained and examined. Note if they are not available with N/A. v'—The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow l"-The site was inspected for signs of breakout. J/'All system components, excluding the Soil Absorption System, have been located on the site. L/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth 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 existing information or approximated by non-intrusive methods. Z'The facility uv-1m. (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: U 3`� Wk.w Sw \ Owner: tAk �? .,\1 -'I Date of Inspection: S FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: Q Garbage grinder (yes or no):`cgs Laundry connected to system (yes or no):*,(c.) Seasonal use (yes or no): "4e5 Water meter readings, if available: NIA Last date of occupancy: OCl- COMMERCIAUINDUSTRIAL: *Type of establishment: Design flow:_ gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: MA System pumped as part of inspection: (yes or no) A10 If yes, volume puMf)(CI gallons 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: t'16W I Q t Mn \CA ow^ems Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 r f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: %3L� lam)"^Os`V�T t�1 3 Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade:AO Material of construction: J:L-C-Oncrete _metal _FRP =other(explain) Dimensions: 6;? X `/O X J Sludge depth: d" / u Distance from top of sludge to bottom of outlet tee or baffle:_ 9 Scum thickness: 0,= yr! Distance from top of scum to top of outlet tee or baffle: /✓A Distance from bottom of scum to bottom of outlet tee or baffle: NA S`- roz e Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level jn relation too 'let invert, s rut ral integrity, evidence of leakage, etc.) l� /� � �5���'I - (�u% omc I�}20."'D /;1 �7 - l-.c�Lc-.e' w S/Ju�c� !vI ec rQ n: o /o M GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _meta6-_FRP —other(explain) Dimensions: Scum thickness: Distance from top of stun, to top of outlet tee or baffle: Distance from bottom of cr'um t- bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 134 i�2s--�T w�Owner: M 2.?P,A-J 12JY�.✓1,�Av✓t r Date of Inspection: k kciS ' � • - TIGHT OR HOLDING TANK:-&�4 , (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) �1� ��x i7�°e S � Z PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 to Y'i.i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: r.^1 114A W` Date of Inspection: a�1 ,otq 5 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:—A /1aoo 9�e�c�i P1�f ST,-7e- leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, tc.) /Va �S/6/�S D a9n4 2v6'em CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ht,..T�j sac _..--...._ c Q \A4 A � � DEPTH TO GROUNDWATER Depth to groundwater: Z&5- feet �� o� S'�5 n / method of determination or approximation: tl�• G.S. �� T Wei (G✓ a - CdCT- l ' (revised 8/15/95) 9 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL.PROTECTION r `V TITLE 5 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: 1203 L (�y Date of Inspection: LV/0/0 / Name of Inspector:jplease print mil. 10 Company Name. Mailing Address: Telephone Number: !SQr, 7'7 j.gLi!a I 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 pursuan7passes ection 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority F is Inspector's Signature: Date: /0 P1 The system inspector shall suLit 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 ****'Phis 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 6/15/20.00 page 1 ti I i C6 �N SL q C1n` t Al 4 - - . __., ,.. -- - ;;.: Y _ "'1.it r i - r ; (�J�� J�l � 1 �" �+ " °,..—-, `y'�" ` _ ;: TO..1. Q g�� _ 1.. _ ' s Y t r .L •Q - .h �.a. E; -"'#>z` .cr- ,r 1! r ' ,1:C3CATIO t:"t 3 L:l 5�i C W SEW kGE`# s :its a . %mn !� fi , a, x VII,LACE: O S f eN,.`'C" ASSESSOR'S MAP&.L `�r-; � __ d �are�t" rf�� e f INcTALLER'S NAME&PHONE NOGG GCS r o - Nfil�, � « I de a . �� �� I x ; k jwr f- �4r r� DO`Q C/3I. r ��f d r a ; SEPTIC TANK CAPACITY F r ; � = S r^^° dir ' CreA It ref-f'�F�4sZe� LEACHING FAcii..rrY.,( ) ) a 6 X 8 , 4r 5,,� F? d - -'i . . size NO.OF BEDROOMS ll y f s r BUILDER OR OWNER �Av V, 2rn.n ch ryl r r=s.?14+sF H�lh'!{t e;sy�: t. £ +-.Y ? 1 ,<. f :: •. ^"""_ �, i r .. S ,. , 1 r f..r x ;Hncf¢IP p.d{�tl.rh'"s i„+b.Ftv �; a ,PERMTT-DATE i S s CONII'LIANCE:DATE $. f 3'! - f l tit St -s!'Pe'', Separation Distance Between the X r t, k{r;�tr , d1 :1 ,t7i i1 _ f f 1}1�1 f dG t $?,Tf S rk d° X. Ma�umum Adjusted Groundwater Table and Bottom of Leaching FaciLty jB> Feet h` (' ,`, 1;,' 1 ,41 �i1 Private Waier Supply Well" d Leaching FaciLty (If any wells e�ust`` s s "'`�lr :� 1 3,rr : ; i'".. j_:," oh site or witlnn 2®Q feet ofleachi�ig fac�hCy)t�i Feet j Tp f r;r; r Edge of Wetland and Leactung FaciLty(If any wetlands exist wxthtn 30.0 fee of leaching"f 1 Feet)' Itt t ! 1. F,rf ,i t .4ifishedhy x. : ..,.: :�; S �x.T ' S.V S ! } 1 S 3 ':U f4 a % t x a, q ,, 5 t-. x.h s 2,? �. r ; (t(' Y;y , l. -fc. t^s <61"r 1j `J t . 1 rj 1 e i IM M j "r ,�,ey '' ' -r s 1 tn: : � I., k t.i' - �.a a, i y' e�if1lri y�,r I a i Wa - _v .r - 1-... X J .. . , . . .:. - _ .. - f -: - - , ., ` - ,- " .:��,t� -,� -',-,`�.[.��::, , .. �,:.. .1 -:."�: � �' 9 }ae 4 3 .5. _ -� _ _ +--+ - W . . _. - P -- , a, P :' . ,: r -§� ;y..-. -. i - .. .... ...- .. _ .. . n w .. .. ! �. S ,' .. f ,- _ . - F _ i ,. - f Fry.T�a� . a �. 1 7` 1 l - - .- ,' -r(A�a, , �-. )y' a f �. :_... - . _ ... 3,y 'D SST30,, ay' - : .. `iY' I''T 3 Lt /. - j �6, �:ra6 . i OfTfT� Torn of Barnstable H T It De artme aARNSTABLE p nt of Health, Safety, and Environmental Services MASS. 0. Public Health Division -. ATFD 1vlA�A 367 Main Street, H annis MA 02601 ZMI I 1 Date: 7Z Number of pages to follow: / To: From: Phone: Phone: 508=862-4644 Fax phone: T--37s6 Fax phone: 508-790-6304 Cc: -REMARKS: ❑ Urgent �For.your review ❑ Reply ASAP ❑ Please comment CC Ccw tea„-��y��� �7 ��- 7Y-z z a r HP OfficeJet Fax Log Report for Personal Printer/Fax/Copier BARNSTABLE HEALTH DEPT 5087906304 Jul-13-01 07:56 Identification Result Pages Tvne Date. Time Duration Diagnostic 917812782260 OK 02 Sent Jul-13 07:55 00:01:13 002586030022 1.2.0 2.8 r HP OfficeJet Fax Log Report for Personal Printer/Fax/Copier BARNSTABLE HEALTH DEPT 5087906304 Jul-13-01 07:54 Identification Result Paces Tune Date Time Duration Diagnostic 915084283750 OK 02 Sent Jul-13 07:52 00:01:43 002584030022 1.2.0 2.8 07/31/2001 15:05 15084283750 BAXTER,NYE&HOLMGREN PAGE 01 lT' �✓*' z v�- Baxter, Nye & Holmgren,Inc. '6 812 Main Street � � . Osterville,Massachusetts 02655 0 J. Land Surveyors & Civil Engineers . 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