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Home My WebLink About0639 RACE LANE - Health 639 Race Lane Marstons Mills- A' ' 103 03' ` SMEAD No. H163Y UPC 10271 smead.com • Made In USA ��5 �a� 3 �� 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments = ' �M 639 RACE LANE Property Address ,ar ANTHONY GRAY ¢ Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information �! Ia9da on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK NARDONE use the return Name of Inspector key. BRIDGE HOME AND SEPTIC INSPECTION SERVICE r� Company Name 40 JACQUELINE LANE Company Address PLYMOUTH MA 02360 City/Town State Zip Code 508-747-0611 SI 3895 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority H � 6 __� 04/02/2018 Inspettor s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 klp VS I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. , *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is. required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for eery MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? PUMP TRUCK Reason for pumping: MAINTENANCE Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow,cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): SEPTIC TANK AND 2 PITS IN SERIES t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts U W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 RACE'LAN E Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: TANK AND FIRST PIT ORIGINAL, SECOND PIT INSTALLED 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Materiai of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): GOOD CONDITION Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 8" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 .. page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? 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.): TANK IN GOOD CONDITION, ALL TEES IN PLACE, LIQUID AT PROPER LEVELS, TANK PUMPED AS PART OF INSPECTION Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M s 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PumpChamber locate on site plan): ( p ) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): ALL CONDITIONS NORMAL, NO SIGNS OF FAILURE, SECOND PIT LIQUID LEVEL 5 FEET BELOW INVERT Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimens ons Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >12 Estimated depth to high round water: p g g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) Q Accessed USGS database -explain: You must describe how you established the high ground water elevation: ELEVATIONS OF LOT , DEPTH OF BASEMENT DRY Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 639 RACE LANE Property Address ANTHONY GRAY Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 04/02/2018 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I i 37 t7 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION M It Y.c v� I y O7M SJ0 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A , CERTIFICATION Property Address: #639 Race Lane Marstons Mills,MA Owner's Name: Linda J.Rizkallah Owner's Address: 639 Race Lane ' Marstons,Mills, MA I ` Date of Inspection: 04/06/07 '= Name of Inspector: (please print) Mr. Carmen E. Shayw i Company Name: Shay Environmental Services,Inc. _ -- Mailing Address: 34 Thatchers Lane ' East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes Conditionally Passes �S";'o ,c; ds Further Evaluation by the Local Approving Authori to Fail ` = E T Inspector's Si natur : Date: 04/06/07 P g The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Cesspool Acting as a Septic Tank with an Overflow Leach Pit. Liquid Level in Leach Pit meets the required inspection criteria for Title V. No Liquid observed in pit. Stain line observed at 3'. 3 Effective Sidewall Available. ****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 I r �Page 2ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #639 Race Lane Marstons Mills.MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 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 failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 D. System Failure Criteria applicable to all systems: You must indicate yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (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—I WPA)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 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX _ Pumping information was provided by the owner,occupant, or Board of Health XX Were any of the system components pumped out in the previous two weeks XX _ Has the system received normal flows in the previous two week period XX Have large volumes of water been introduced to the system recently or as part of this inspection? XX _Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up ? XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site'? XX _ 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 ? XX _ 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 XX _ Existing information. For example,a plan at the Board of Health. XX _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #639 Race Lane Marstons Mills, ills MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):_3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Currently occupied 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: Unknown Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: 1960's-per Homeowners&BOH Records Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4639 Race Lane Marstons Mills,MA Owner: Linda J. Rizkallah Date of Inspection: 04/06/07 BUILDING SEWER(locate on site plan) Depth below grade:_20" Materials of construction: _cast iron XX_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:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottoms of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons D.-sign 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 U ON BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): 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.): T ., . . .„ 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type 1 leaching pits,number: 6' diam by 6' deep Overflow Leach Pit leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone around SAS with a 6' probe with no evidence of hydraulic failure noted. Inspection inside Cesspool revealed no standing water. 3'stain line observed. CESSPOOLS: i—ACTING AS SEPTIC TANK (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1_ Depth—top of liquid to inlet invert: No liquid—cesspool was dry from non occupancy. Depth of solids layer: 5.5 Depth of scum layer: No scum Dimensions of cesspool: 6' x 6' Materials of construction: Cement Block Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Stain lin indicated liquid level equal with outlet tee invert and overflows into overflow Properly. 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 I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 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. Isalene Street Swing Ties: Water',Line A- Cesspool—59.5. B- Cesspool—61' A—Leach Pit-74' B—Leach Pit—65' Exist House A B Cesspool Acting As A Septic Tank O 0 Overflow f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #639 Race Lane Marstons Mills,MA Owner: Linda J.Rizkallah Date of Inspection: 04/06/07 SITE EXAM Slope Surface water -'/4 to ''/z mile+/- Check cellar -Yes Shallow wells—None Estimated depth to ground water 15+/- 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: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Inspector has performed perc tests in area. Per USGS MAP PLATE 2: Elev.of Ground=80 Feet Elev.Of Groundwater=45 Feet Elev. Of Bottom of Leach Pit 72 Feet Therefore: 72—45 =27 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well SDW253 : 2.1 feet Adjusted Groundwater Separation=72'—47.1 =24.9 feet between bottom of Overflow and ad'.groundwater Grade=Elev. 80 feet Overflow Cesspool Bottom of Overflow=Elev. 72 feet Adj. Groundwater=Elev.47.1 TOWN.OF BARNSTABLE WAGE # 0 L... � �C� t-C�(1Q SE �' 7 r. i�II,LAGE M + Mills ASSESSOR'S MAP& LOT / ')NSTALLER'S NAME&PHONE NO. _SEPTIC TANK CAPACITY r Ol LEACHING FACILITY: (type) G GV' k- (size) ('�(o NO.OF BEDROOMS BUILDER OR OWNER 1—IfI6C= RkIK-CA\\C-An PERMITDATE: CC —C?"B -1- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility c;�4,9 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of edan and ching Facility(If any wetlands exist w' acili Feet [thin 300 feet c eac ng f ty) Furnished by �A U-1 w- TOWN OF BARNSTABLE 03 I:OrATION , ?,� �� , SEWAGE # � VILLAGE ASSESSOR'S MAP Sz LOT 10�/ 41 INSTALLER'S NAME & PHONE NO. F SEPTIC TANK CAPACITY r ' LEACHING FACILITY:(type) (size) 1000 NO. OF BEDROOMS PRIVATE WELL OR UBLI�WAT�ER BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: G 9 7 Ia VARIANCE GRANTED: Yes No L--- co \4' �I 6 �0 �31. f. ASSESSORS MAP NO: D No...S -.. 7 PARCEL NO: `� FE$.... ..�-'.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................ .N----------------OF.. - ---------------------......_...----------- Apptiratiou for Ph4poii ai Works Tom3 rttrtiu rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at, , 17 .... __ _9 .........................._ .T. .Kv - ...... -tit............................................................... location-Address or Lot No. ..... �'�-p'�r'��.----.....� ��C, -------------------------- ----�z ------._� .C:3:.---- ...... owner Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms______ ___________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures _____________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. . 1:4 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—NTo_ ____________________ Width.................... Total Length......... _._.Total leaching area....................sq. ft. 3 Seepage Pit No_________ _________ Diameter._..___........ Depth below inlet.....3_.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,4 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........................ . -------------------------••----••-•----•---------------•-_ -------------------•-------- ----------- -•---•-------------------•----•---- x �® � �� Description of Soil....... f----- -- -' - ................ �/ - -- --------------------•-•------------- 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 L I_!E4 5 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 the board of health. g Signed-------�• "Q. `�� ~�� --•-------••---------------•- p-•�{ ate ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:------•-------••----•---•-----------•--------------•--...----------------------------------•-•----------•---•- ----•---•••------------------•---•-•-•---...---------•-•---------•---•---•--------•...-•---------...__....__....----••---•----------------------...------------•--------- --------•---------•-----•----•- q Date Permit No.....9__7.......*3-��-----•-_----------- Issued-..................--------•-----••-----•------•--•---- Date ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .- .4......1/-- -------------OF;&..(2(vsrr. .�---------------------...---------..._....... ApplirFation for Disposal Works Tonstrurtiawrtratit Application is hereby made for a Permit to Construct ( ) or Repair (VI an Individual Sewage Disposal System at: ................_.............................................------------------•--••-----•--•-- -----..........._..---•--.....---•----••••---------------•---•---...........-•-------.........._.. .... - Location-Address or Lot No.........-•---••-••._.... Owner Address a �C`GU 1 yy F-l•�C_tC� .��:a.:. ' ._.. � 6 � �" �r rlr�.� -..... -------- ---- ---- --------------- ----------•- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms_ ----.--•--. _----Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria a' Other fixtures -------------------------------- - . W Design Flow............................................gallons per person per day. Total daily flow.............................__-.............gallons. WSeptic Tank—Liquid'capacity..........__gallons Length................ Width............... Diameter................ Depth................ x Disposal Trench—N?o. ..................... Width.................... Total Length............ Total leaching area--------------------sq. ft. Seepage Pit No.---------_-_______ Diameter.__...i ..._.___. Depth below inlet.....5............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date..................... -------------•---- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ic, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ..........-.........................................................................................---•... ••------------•-----••-•--•----••--•--------- Description of Soil `- -I ......../�._.� x ...`:sv. .................... -•----. 12..------.... V ..............................................----------------•-----------------•--••--••----•-•----•....--------------------•---••••••--•--•-------•---••-•-•-----•••••-••-••----•-----•---•••---_.•--- 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 i T" ;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 the board of health. Signed....... ..... --- sD �A ate ApplicationApproved By.................................................................................................. --•-•-•--------------------•• ------ Date Application Disapproved for the following reasons---------------••--.............--•-----•---------------•-----------------------•----------------------....- ..-••-•-...•---•-••....-•••---•-------------•-------•-••------------------•---•-•----------._........---•-••.......--••........_..•-----•---•-•-•••---------•••--•-•----•-------•---------••------------ Date PermitNo....17------- 2.- ........................ Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF..P( A�ZN� 3..a. .................. Tnrtif irFatr of TnntpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�r by......JI.y 1 ru-----•r k t L.K.t'V.............................................--...................................................................................................... G Installer .......... •-•------------•---------------------------•--•-•------------------•---....---•---•----•... has been installed in accordance with the provisions of 1_LT1E 7 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. -.7."_ i'. ............... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................6....... .'.. ....-----•-------••---. Inspector........ ----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t/- ^ ` '�.�......................oF`` 2Ya.STr �,. ..--•---------......-----••-•---••----.. N0...6..7- -e5... FEE.'�.r... -- Disposal Works Tonstrnrtion Frrutit Permission is hereby granted ...... -------•-•---------------•----------------------------...-•------------•-••---•----•--•--••------- to Construct ( ) or Repair (tooTan Individual Sewage Disposal System at No...C .........sz .......L N....--•--------. Street _ as shown on the application for Disposal Works Construction Permit NS7:_1A..... Dated.......................................... B He DATE................................................................................ oard of FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE 63 cy� LOCATION ,"?� �� e SEWAGE # jVILLAGE ,Q 0 - •� ASSESSORS MAP 6z LOT) i.. INSTALLERS NAME PHONE NO. -SEPTIC`TANK CAPACITY LEACHING FACILITY:(type) (size) (000 NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER j BUILDER OR OWNER DATE PERMIT ISSUED: -" i • 1 DATE :,-COMPLIANCE ISSUED: 9 7 I VARIANCE GRANTED: Yes No Lam' RZ,�c Q L } '`a �o v lC f TOWN OF BARNSTAbLE o LOCATION ,( SEWA E LOC G # VILLAGE , .Q c,C "k, ASSESSOR'S MAP & LOT d �1 INSTALLER'S NAME & PHONE NO. c,.\L 2 � -SEPTIC TANK CAPACITY I LEACHING FACILITY:(type) (size) ® . NO. OF BEDROOMS PRIVATE WELL OR C�LBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �� 7 4 DATE :COMPLIANCE ISSUED: VARIANCE GRANTED: `Yes No � '�Ck, C) 4 J �k0 tp Commonwealth of Massachusetts Title 5 Official In �s r��1, _ spection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t�3°l M Race Lane Property Address Option 1 rad"�. y Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. City(Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab Key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspections Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification _ I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection�Ahe inspection was performed based on my training and experience in the proper function andThaintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section,!5.340 of Title 5(310 CMR 15.000). The system: i t ._ - ® Passes ❑ Conditionally Passes ❑ Fads Zrj ❑ Needs Further Evaluation by the Local Approving Authority 11/18/07 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 629 Race Lane Property Address Option 1 Owner Owner's Name information is Marstons Mills MA 02648 11/15/07 required for State Zip Code Date of Inspection every page. Citylrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure.is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 t5insp•08106 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is Marstons Mills MA 02648 11/15/07 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (coot.): ❑ 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: >* Isis performed at a DEP certified laboratory, for coliform well water analysis,This system passes if the Y presence of am monia nitrogen and nitrate nitrogen is equal to or bacteria indicates absent and the prese 9 less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title 5'Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 t5insp-08106 Commonwealth of !Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is ' Marstons Mills MA 02648 11/15/07 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified absent and the presence laboratory,for fecal coliforin bacteria indicates abs p II of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp-08/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 629 Race Lane Property Address Option 1 Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp-08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 629 Race Lane Property Address Option 1 Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4101/07Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owners Name information is required for Marstons Mills MA 02648 11/15/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 25 years Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is Marstons Mills MA 02648 11/15/07 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Building Sewer(locate on site plan): 3.0 Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 t5insp-08/06 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is Marstons Mills MA 02648 11/15/07 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of"last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 629 Race Lane Property Address Option 1 Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. CityrTown, State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): This system has a 6'x6' precast pit surrounded by one foot of stone. The pit was dry with a stain line one foot up. t5insp•08/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j 629 Race Lane Property Address Option 1 Owner Owner's Name information is required for Marstons Mills MA 02648 11/15/07 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 inline Depth—top of liquid to inlet invert 5.1' Depth of solids layer 2" Depth of scum layer 0" Dimensions of cesspool 5x5 Materials of construction dry well blocks Indicaticn of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): This system has a 5x5 dry well block cesspool which was dry with a stain line at the outlet invert. The cessspool was sound with a tee in place Privy(Iccate 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.): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Race Lane Property Address Option 1 Owner Owner's Name information is Marstons Mills MA 02648 11/15/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Vt� 4 6f &1D 6 t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Race!Lane Property Address Option 1 Owner Owners Name information is required for Marstons Mills MA 02648 11/15/07 every page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Maps show an elevation of over twenty feet t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 V � � I t W .. TOWN OF BARNSTABLE 0® L -6 03 ` OCATION�, �� SEWAGE-# ��" '��•� [LLAGE , C3CC ASS ESS S. MAP 6: LOTS 1STALLER'S NAME & PHONE NO. OPTIC TANK CAPACITY i SACHING FACILITY:(type) (size) l 00 D. OF BEDROOMS PRIVATE WELL OR UBLIC TER JILDER OR OWNER i kTE PERMIT ISSUED: — �- r • i kTE COLIPLIANCE ISSUED: a ►RIANCE GRANTED: Yes No ��•. i