Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0009 CAITLYN CIRCLE - Health
19 Caitlyn Circle (Marstons Mills) IA �I 111 UPC 12934 eco,,"el Nf 2 HpSTiNGS,MN _ 1 � . � z A . + -�`✓`z� No Fps.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T.overt.........._0F........ / .le. .j. .. . . Appliration for Disposal Works Tonstrurtion Vrrmit . Application is hereby made for a Permit to Construct 1-11"Or Repair an Individual Sewage Disposal System at: .............. ........ .............................................. Loc n-Add or Lot No. -A* ................/0a_,Y_ff. . .....A Owner dress e,Z e-3 .......... ......... Installer Address U Type of Building Size Lot.....4.4,_�Ay..Sq. feet 4 Dwelling—No. of Bedrooms.............. ..........................Expansion Attic Garbage Grinder yp Other of Buildin g ............................ No. of persons._____ ..._....._..__._...Y.................. Showers Cafeteria 04 Other fixtures Design Flow__________________15S -.........._._.._._...gallons per person per day. Total daily flow---_--_------3%34................gallons. 1:4 Septic Tank—Liquid capacity./,O4OtOgallons Length._8:!.4... Width... Diameter---------------- Depth----4.-e- :T., Disposal Trench—No..................... Width.......-............r Total Length.._..........._..... Total leaching area....................sq. f t. Seepage Pit No._...__./---------- Diameter......../Z....... Depth below inlet......4-.6..... Total leaching area..:941....sq. ft. Z Other Distribution box (wj Dosing tank Percolation Test Results Performed by.....A0Z-4(�e4Z,;;n 1141W.......................... Date..._ ......... Test Pit No. I.....2.......minutesperinch Depth of Test Pit.......13...... Depth to ground water...., a,e3_4=-_ 44 Test Pit No. 2................minutes per inch Depth of Test Pit...___...._......_.. Depth to ground water......__............_.._ P4 .....................I.........................................I................................................................ 0 Description of Soil.......................................a..n.z...... �4 U ......................................................................................................................................................................................................... W x ........................................................................................................................................................................................................ U Nature 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'JITL U 5 of the State'S it'ary Code— The undersigned further agrees not to place the system in ;�ation until Cer t(e of Compl* has been issued_by the board-of health. Signed------'....`, ............................................... ....f/0"(--------- X D 7 .......................... icat . ...... ....... V pplication Approved By.... '-------, .............. Application Disapproved for the following rdsons:..............................................................................................Date............. ------------*-----------*--------------*------------*----------*--------------------- -------------------------------------------------------------------------------------------------*------— V, —lot, D PermitNo--------09 -- -------w........................... Issued.............................................ate........ A Date 'J q TOWN OF BARNSTABLE ff� 1 CAI�TIIIU clfzcl c� LOCATION C—c�'4 (O SEWAGE VILLAGE ASSESSOR'S MAP & LOT 7 INSTALLER'S NAME & PHONE NO. e . SEPTIC TANK CAPACITY LEACHING FACILITY:(type) L��c Q '� (size) ll NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER Co, DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: ) VARIANCE GRANTED: Yes No r I� s� L v-� to No.D_.t........_._....._ FEB......... ......... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF......./� �-i���.t�. � ...................................... Appliration for Disposal Works Tonstrurtinn Prrutit Application is hereby made for a Permit to Construct (w' or Repair ( ) an Individual Sewage Disposal System at: or / .............................................. tion-Add ess or Lot No. .7., /X� ...... - Owner / ress �j Z e_.?ZL W Installer Address Type of Building Size Lot....4-4-.--5--_._.--:L-Sq. feet V Dwelling—No. of Bedrooms............. ..........................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons.....Y.................. Showers ( ) — Cafeteria ( ) P4 Other fixtures -------------------------------- . W Design Flow.................. .. .......:.........gallons per person per day. Total daily flow__.............._3.3. ................gallons. WSeptic Tank—Liquid'capacityl,�P4G.gallons Length..B z�.... Width--Q-.10.. Diameter................ Depth.... -. .. x Disposal Trench—No. .................... Width.................... Total Length..-...AK........... Total leaching area....................sq. ft. Seepage Pit No......../_----------- Diameter.......AZ....... Depth below inlet........ _ Total leaching area..7.d.7.....sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by.... !' :tc __.. a _h- ---------------------------- Date....2 ........... ,-1 Test Pit No. 1.....Z.......minutes per inch Depth of Test Pit-------/3....... Depth to ground �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•-----•-••----•-------•-••-•---•----••..................•-•--------••..............---............._._._......--••••------.... O Description of Soil r�'z, -----Z...... W ...........................•------•----•---•----------•-----------••---•--•------•--•-----------------•-----------------------------...-•-•----------------•---------------------....._.........---.... U Nature 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 TITTIE 5 of the State S nitary Code—The undersigned further agrees not to place the system in "ranti)C ctalte, off Comp ' e has been issued b the board of health. r /� fa'_ Signed---....-- D3Application Approved BY -----y.....--y-----Jasons: --------- -------............................................. ---- . ...D.. ......... ate Application Disapproved for the following _._......-•---------------•-----•--------•--•--••--•---•---•---------•-•--------••--.........--••---•-••-....._ ..-•----....--•------------•-----------------•-------------••-•---...-•-•-------------......-•------•---•.. Date PermitNo.-----= L' ... `-------------------------- Issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ 1Z ..............OF............le�o ' Trr#ifiratr of Toutpliattrr THI. IS TO CERTIFY, That the Individual Sewage Disposal System constructed (t/) or Repaired ( ) b ...09 5�'�t . Y ..-•---- Installer at•---�=�•�--•---•---1�--•-•-••.1�..---------------�' '' .l ... . ..--•--•------ -" - 3a�`..S .------- .... d . .`.......----------•--•----....•........ has been installed in accordance with the provisions of TI I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....:..........._v_ ..._.......... dated_...___ _�. ..�. �................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................- ----- ---------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEE....... Disposal Works Tnntrnrtion rrntit ��� Permission is hereby granted--•---•--==.t .._.. to Construct ( Y or Repair ( ) an Individual Sewage Disposal System atNo...------ 3.......4aZ-21.......jP'(,5_;r -'R_11-................&YA =.�.Zb ':$------.....M 1.4./-..�+'�".................................................... Street_ U as shown on th/,�) plication for Disposal Works Construction Permii�t o........../.........•Dated.......................................... ....................................................... Board of Health DATE........---•- -- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS { t SITE PLAN SHEET I OF? SCALE: I = SO ©-F c` 3�s .� •vil S o Qk \ I r �e Sr TP \ o \ -6y Il � 373 .3/ L 710 Z 7- A /J OF MLLIAM rr M Flo. 1 w i - 5T���� . . . ni Ln�4i �G(�a�u.���c__, FORS- )'�• /�?L- , .._. • .' , . �� - REGISTERED LAND SURVEYOR Z o T /D 7- ZONE PLAN .REF: GL'T o r N/AP 57 F'c! S DATE ;IA;12'' BENCH MARK DATUM WM. M. WARWICK 8 ASSOC., INC. DOMESTIC WATER SOURCE--75 ryw BOX 801 - NORTH FA L MOUTH FLOOD ZONE. MASS. 02556 - (6I7) 563 -26 38 i LEACHING 3ASIN SECTION NOT TO SCALE shccsl 2 o f Z 24 C.I MH COVER EARTH F/L L BRICK AND MORTAR COURSES AS REO'D• TO BRING COVER TO GRADE --LL B'FLOW LINE INLET "TO%" WASHED PEASTONE FREE Of IRONS, PIPE FINES AND DUST /N PLACE if ' •',�3M OPENING WITH 4%B" /RONSO FINES RAND OUST SHED �N PLACEE FREE OF OUTER DIAMETER AND 1414" INSIDE D/AMETEK 1. CONCRETE TO BE 4000 PSI 26 DAYS I r 2. REINFORCED WITH 6%6" NO. 6 GA. W.W.M. 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS 40,r3 -- s'o" 4. NUMBER OF PITS REQUIRED I MIN. I 1Z' NOTE: EXCAVATE TO ELEVATION 43•4-OR EFFECTIVE DIAMETER (NOT To EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL wATER TABLE - "mAalLOAM AND CLAY BENEATH PIT. R�PLACE EXCAVATED MATERIAL WITH CLEAN TYP/CAL PROFILE' GRAVEL TO DESIGNED GRADE. F+s•�tc. s"3S —/B"STD. LT. WGT. C.I.NH COVER 5'4.$• Si�.Q .0 4.d i I fog 4"B/T.FIBER PIPE 4'C.I.P/PE TIGHT JOINT OUTLET LEVEL FLOW LINE DWELLING O O O TO FIRST JOINT I .Sd./D '� �4 S•/r3� i 10�j O 0 1 1 (. C.I. TEE S'1-24 F `-'�— 111000 00 1 1 1 I ; i •� �'/ j STD. PRECAST CONC. /ST. BOX TO BE :f 000 00 1 1 9WAL.SEPTIC TANK INSTALLED ON LEVEL, $/r 11 1 0 00 0 0 0 1 I I i•;•; STABLE BASE 1 11 100 0 0 0 ) ' i •.' •.. I O 0 1 1 � sEPT/C TANK To BE 1 '1 0 0 0 00 1 1 I INSTALLED ON LEVEL 1 if 100 1 O 0 1 1 ' ' STABLE BASE. 1 1 000 00 1 1 1 LEACHING BASIN i 1 0 A Qp 0 00 0 1 i BASE TO BE LEVEL I b O l 00 1 1 , SOIL AND PERC. DATA PERC. RATE Z MIN. /IN. 0 TEST PIT NO. 1 0" TEST PIT NO. 2 2 Ta`o � .St•iloisGi/ TEST BY - •!�r�ucc /-��f�/ WITNESSED. BY' _7`: i TEST PIT GR. EL. ✓s4__f4l DATE: 7, ZaZA DESIGN DATA GENERAL" NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. 'DISPOSAL �mn� SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL. 3�GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK /oho GqL• ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREA x•S~GAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA t•o, GAL./SQ,FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977.• LEACHING REQUIRED•24° SQ.FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL.LEACHING AREA OF HEALTH. �SQ:FT. .AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/4, / FT. UNLESS INDICATED OTHERWISE, >� SEWAGE DISPOSAL SYSTEM MARTIN E. FOR •MORAN v~i 1.07E,p f23417�Q �Ularszcrn# mlve , al _41yzle "ar SCALE AS INDICATED DATE •3 ��� .. , WM. .M.-,WARWICK 8 ASSOC., INC. . 8OX :801 - -NORTH FALMOUTH ` MASS. 02556 - (617) 563 -2638 PROFESSIONAL ENGINEER COMMONWEALTH OF MASSACHUSETTS EXECI TIVE,OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAI~, PROTECTION i tl7 TITLE 5 OFFICIAL INSPECTION FORM-.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C r G 2 s 144,'l s 1wa. oz /f RECEIVE® Owner's Name: Ciu/ylnGt 9" {per Owner's Address:- ef cai,tiv. 0 r Mu�S ays M�' s /� D�Lyb WAR 1 3 2001 Date of Inspection: 3—?—o TT ,/ TOWS OF BARNSTABLE Name of Inspector: (please print) J o 4 g f, Aa AO HEALTH DEPT. Company Name: qa c 3a�k ne...Szrv�c.0 Mailing Address: 2 lU 1 /LJa r s 0"s Telephone Number: Sy 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 qf-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: y Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C Date: The system inspector shall su mit a copy of this inspection report to the-Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments . ***.*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 61I 2000 page 1 }. Page 2 of l l OFFICIAL INSPECTION FORM—NCjT 'OR'YOIi7NTARYzASSESSMr) 5; . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:A CERTIFICATION(caarinuedi Property Address: q Cc�i H h L'i -C, Maus cc�c / 1 • Owner:. aw y-eti C F yi b iwi-7' Date of Inspection: Inspection Summary: Check-A,B,C,D or E/ALWAYS complete ail ot'Sktlom.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: •` '.,'Ar, 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 faihme its 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 breakout.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)a:z replaced obstruction is removed distribution box is leveled or.replaced ND explain: The system required pumping more than'4 times a year dui to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIALINSPECTION FORM NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART X. CERTIFICATION;(continued) Property Address: lam S vh s, s 0, Owner: rlhc.e i v Date of Inspection: 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,s4foy 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 pn'vironment: _ .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. _ The system has a septic tank and,SAS and the SAS is less than 100 feet but 50 feet or more frond 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 poVi;tion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than'§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 I 1 OFFICIAL INSPECTION FORM—NOT-FORRVOL[JNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP05AI'SYSTEM;INSPECTION OR11 ' PART•A ., . . Y; CERTIFICATI( N.�* c6adaued) Property Address: i fJ h 611--dv Owner: L�►w�shtt �/i �r1 Date of Inspection: 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 cesiAol Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool o Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow k-,Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _v Any portion of the SAS,cesspool or privy is below high ground water elevation. _✓Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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`301eet'fromwprivate water supply well with no acceptable water quality analysis. [This system passe§,ifthe weN,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.] ido (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 tocor ect the failure. E. Large Systems: :ir'�, 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 thefollowhi9 . (The following criteria apply to large systems in addition to the crh ria 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 f Page 5 of 11 OFFICIAfINSPECTIONTORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPESTION FORM PART B CHECKLIST Property Address: Ca t/ r� /rUp Owner: Date of Inspection: '�l—2--0/ 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? L,/ 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 I?vailable note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? r�_ Was the site inspected for signs of break out? V _ Were all system components,excluding the SAS,located on site? _✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 .'1 y Page 6 of l 1 OFFICIAL INSPECTION.FORM—NOT FOR YOI UNT4yY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPE&ION FORM PART C SYSTEM INFORMATION Property Address: CN / n C/1"�P Owner: La�vy�Hce lei' hr.t Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_2__ Number of bedrooms(actual):3 , DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): `3V0 Number of current residents: a Does residence have a garbage grinder(yes or no):�o Is laundry on a separate sewage system(yes or no):.Mp [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):..�e>,�� - /9 9 9 = 3 y 7 fpd ,H`69flh;�r 4 wm y,1-, d ePf Water meter readings,if asailable`(last 2 years usage(gpd)): ZdVO `1'Y3 gpal �nclNd,�9 luk.h ���.,��rs Sump pump(yes or no): Alo Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_` Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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 curwnt operation and marijtenance 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 or no):_ 6 i Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q C"'f/4n Cir��o f NIl%s,IK Owner: �UwyfHE1 /�ihl�if Date of Inspection: 3—2—d/ BUILDING SEWER(locate on site plan) Depth below grade: 34 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: /B" .Material of construction: concrete metal_fiberglass_polyethylene _other(explain) . If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes Q-W):_(attach a copy of certificate) r Dimensions:. Sludge depth: /2 Distance from top of sludge to bottom of outlet tee or baffle: 12" Scum thickness: s/Md Distance from top of scum to top of outlet tee or baffle: — Distance from bottom of scum to bottom of outlet tee or baffle: _ How were dimensions determined: 4410a r S rear Comments(on pumping recommendations,inlet and outlet tee or baffle condition,.structural integrity,liquid levels as related to outlet invert,,evidence of.leaka e,etc.): OS� di Ni� hR cl Garir►c hull 60 c' tin�c �py �d(��t� Ih GlOvd' COh�� /dh 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 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOTj?QR�V01.U!1TAAY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM. , FAR .0 y SYSTEM INFORMATION(continued) Property Address: G !� � h C/rC6✓ ors a W. owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspettimnNtate an site plan) Depth below grade: ''^�r 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:_r 4 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:e_ q Lry evidence of Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any leakage into or out of 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.): 8 s Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION(continu4}1,r i Property Address: �G vI c:s r ,71s, Owner: 'a .'hc 2 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number!%1_ 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.): ) J 40 / rN ' IN Q / ' QGG^ ! � • 1�0 S/r'J7S 1` rt1Hl/(" �ul/Hr� 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.): t� 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.): 9 Page 10 of 11 -ra OFFICIAL INSPECTION FORM'-NOTIZFOX VOCUNT)MV ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C ' SYSTEM INFORMATION(continued) _ lC N it l� � C Property Address: 4� Owner: 4w!/,•,ee Hl' Ott Date of Inspection: 2 . 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. 10 COW j G.ML.�ty e b .,; .� Otdvjv ,.►,, . o��, t`t 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPEITION FORM PART C SYSTEM INFORMATION(continued) Property Address: Me,v s i19'Ij R Owner: )46vylr,re /4/' b"Ie(- Date of Inspection: 3— --o/ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 3J 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) v Accessed USGS database-explain:_ M s w cJiA vts at Towr You must describe how you established the high ground water elevation: 0 C IY7 C, .0 ' . 11 I , Town of Barnstable Regulatory Services ,,oF TO�ti Thomas T. Geiler,Director anxxsrAB14 Public Health Division "�: ��� Thomas McKean,Director Ar�D N1°�s 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 13, 2001. Howard& Marcia Llewellyn P.O. Box 39 Yarmouthport, MA 02675 RE: 9 Caitlyn Circle,Marstons Mills, M.A Dear Mr. & Mrs. Llewellyn; In regards to the septic inspection that was performed on March 2, 2001 at the above referenced property, no repair permit was required for the work done on the septic tank because the repair was so minor. No Certificate of Compliance has been issued because of the above. Sincerely, Glen E. Harrington, R.S. Health Inspector cc: John Aalto I lewellyn/wp/q a COMMONWEALTH OF I`/IASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION l�� TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PA.RTA CERTIFICATION Property Address: C Y G le Mgei s N1,1 s 1W 0 41 F Owner's Name: -evsG i tr t Owner's Address: L " / G j A4 , o"s A4,' .s �1 044'iF Date of Inspection: 3-2—o/ y Name of Inspector: (please print) o Art 9. &140 Company Name: OoAn qa a u�k �e.Srvv�cv Mailing Address: JS2 C(/ _ f 41 Telephone Number: 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..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 " Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ' ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 . , r:� � P. / � �8 �`. �i, r �� • S 7 � + r �.1.� � ' - t { Page 2 of 11 ,OFFICIAL INSPECTION FORM—NO'I'��`OR'VOLUNTAR—YUSSESSM�NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cnntinuedj ` Property Address: ` vj C/1'G Mays c L / ,/ J Owner: c%wylti C-e Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS completeall of Settlon.ii 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 exfiltration or tank fahnre 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;oul 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 s inspection if(with approval of Board of Health): broken pipe(s)am replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more thazi 4 tunes 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: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART CERTIFICATION;(continued) �•�'}' Property Address: 9 lar f vh s s u, Owner: rlht.e i Date of Inspection: 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(l.)(b)that the system is not functioning in a manner which will protect public health,s"fety 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, i[any) determines that the system is functioning in a manner that protects the public health,safety and-6gylronment: _ 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 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 front a private water supply well".Method.used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pol�ution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than'S�pm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: f . 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT,�OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPEM- ON:FORNf• PART.A R, CERTIFICATION.Yc6atk=4) Property Address: q 6 i Y , Cj, Owner: Date of Inspection:_ 3 —2 =o/ D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspectioris Yes No Backup of sewage into facility or system component due to overloaded ouclogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface wateis 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 d Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _v Any portion of the SAS,cesspool or privy is below high ground water elevation. _✓Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a'Zone 1 of a public well. Any portion of a cesspo61 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-froma•private water supply well with no acceptable water quality analysis. [This system passe§91he•well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatlle 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 falb=criteria are triggered.A copy of the analysis must be attached to this forma ido (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 tocomect the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of..vA 000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the-fMllowing: (The following criteria apply to large systems in addition to the critrria 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 I Page 5 of 11 'OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPTION FORM PART B I CHECKLIST Property Address: Ca t/ 1, vti s /Y�• s /N Owner: lliw y��c t /�•' rr� Date of Inspection: -:;-2-a/ 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 V 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 jnoj?vailable 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? 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? — 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)] ` 5 Page 6 of 11 OFFICIAL INSPECTION.FORM-NOT FOR`y'OT;IJNTAP;Y ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPP,&ION FORM PART C SYSTEM INFORMATION Property Address: C.:, ' ,, C, " /, iYl��sr,, /Yl,'1/s,iLfG Owner: Laa c e Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): •'330 Number of current residents: b Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):.nio [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no): 'r �999 3 y y 1 pal Water meter readings,if a3ailable,(last 2 years usage(gpd)): ,2�0 yy3 gpol Sump pump(yes or no):Ala Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank p.r,esent(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part.of the.inspection(yes or 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.Atta~h'a copy of the curmnt 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: I Were sewage odors detected when arriving at the site(yes or no):_ 6 Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:q Ca'Wz.n Cjrc�o • /GfG r s rA NI,lls /Nu Owner:- 1 UwY�a G1 /-/ih1Ny/ Date of Inspection: 3—2—o/ BUILDING SEWER(locate on site plan) Depth below grade: 30 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: /8" Material of construction: concrete metal fiberglass_polyethylene _other(explain) — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes oT'rio):_(attach a copy of certificate) Dimensions: 'i Sludge depth: /2" Distance from top of sludge to bottom of outlet tee or baffle: 12" Scum thickness: �.tl;;; ,„ s/..j Distance from top of scum top of outlet tee or baffle: — Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined. r-y S r✓v� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet ' vert, evidence of. c leaka e, etc.): 1 os�" �7�c� �a z i r.v•r cAt'1�.;� by ba 07P qJ( 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 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.IN CTION FORM, .. SYSTEM INFORNf-ATION(continued) / r< Property Address: Owner: t4 n c�e 1 '-t Date of Inspection: 3-1-`O/ TIGHT or HOLDING TANK: (tank must be pumped at time of iitspegtionXWtatt an site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylehe 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 alarni•and float switches,etc.): DISTRIBUTION BOX: Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_e 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,etq,j�- 77 PUMP CHAMBER: (locate on site plan) .av 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,ew-J If 8- Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ; SYSTEM INFORMATION(continued) Property Address: C i ti C/rc�t �NG vI a r,r .y S Owner: Q the Q Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation.not required) If SAS not located explain why: Type leaching pits,number.` leaching chambers,number: leaching galleries,number: leaching trenches,number, length: 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,darWo soil,condition of vegetation, etc.): , /10 I70 5/ohs 1r 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: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 f Page 10 of 11 OFFICIAL INSPECTION FORM—N� 'FORNOLUNTAY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAY,SYSTEM INSPECTION FORM PART-C . SYSTEM MORMATION(continued) Property Address: Mu Yfaa C Owner: )Awkl"ce plh);v.-t Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.. lt'p�Y �inl .!h 7rcn 1 ., v U 1nC�v/v ,,�• .13 G.nC. E (b 6 6 3L� 2 !o' 6„ 16' 57 0 Is, , 7o cdvj r • .z 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARV�ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: MI+YS Owner: )e4wk4lHre Date of Inspection: 3- 2-o/ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 31 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) '►' v Accessed USGS database-explain: �+ 3 gt Tu,h ku 0 You must describe how you established the high ground water elevation: C, W -I 3 / 11