HomeMy WebLinkAbout0119 AUGUSTA NATIONAL DR - Health 9 AugustaaNational Drive, l '
0
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M. 119 Augusta National Drive, Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is required for every Orleans MA 02653 November 19, 2010
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 A. General Information
filling out forms I / 1
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Richard Judd
use the return Name of Inspector
key.
Richard Judd, R.S.
Val
Company Name
P.O. BOX 1315
Company Address
Harwich MA 02645
CityFrown State Zip Code
508-896-9316 S19584
Telephone Number License Number
B. Certification = "~
I certify that I have personally inspected the sewage disposal system at this address and thatthe
information reported below is true, accurate and complete as of the time of the insbection. The inspection
was performed based on my training and experience in the proper function and maintenancejof oWsite
sewage disposal systems. I am a DEP approved system inspector pursuant too Section!1,5.34050f
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
November 19, 2010
Inspector's Sign u. 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.
Iv
I�
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Augusta National Drive, Cummaquid, MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is
required for every Orleans MA 02653 November 19, 2010
page. CityrTown 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-09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 119 Augusta National Drive Cummaquid, MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins)- P.O. BOX 20
Owner Owners Name
information is
required for every Orleans MA 02653 November 19, 2010
page. Cityrrown State . Zip Code Date of Inspection
B. Certification (cont.)
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 ❑ ND (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 ❑ ND (Explain below):
C Further Evaluation i o s Required b q y 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Augusta National Drive, Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is
required for every Orleans MA 02653 November 19, 2010
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 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 '/z day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Augusta National Drive Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O
Cape Cod Fiv
e Trust&Asset Management(Kristin Perkins)' P.O. BOX 20
Owner Owners Name
information is
required for every Orleans MA 02653 November 19, 2010
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•09/68 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Augusta National Drive Cummaquid MA' Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is required for every Orleans MA 02653 November 19, 2010
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
❑ E 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 breakout?
® ❑ 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): N/A Number of bedrooms (actual): 3
DESIGN flow based on 310.CMR 15.203(for example: 1.10 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
119 Augusta National Drive, Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is
required for every
Orleans MA 02653 November 19, 2010
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Per Health Department:no design plan on file. Property Assessment Lookup indicates the dwelling
was built in 1974,
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? El Yes ® No
Water meter readings, if available last 2 ears usage 09= 33
9 ( Y 9 (gPd)) 08= 22
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: February 2010
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:
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Augusta National Drive, Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owners Name
information is
required for every Orleans MA 02653 November 19, 2010
page. Cityrrown 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: Treatment Plant: 9/1/00.
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) 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):
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N_
119 Augusta National Drive, Cummaguid MA Assessor's Map: 355 Parcel: 9
Property Address --
Betty White Trust C/O Cape Cod Five Trust&Ass
et Management
(Kristin
n Perkins): P.O
. BOX 20Owner Owners Name information is
required for every Orleans MA 02653 November 19, 2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Per BOH: no design plan on file. Septic tank and SAS 1974 per year house was built. Individual
Component installation (d-box) Permit 96-673 issued 12/20/96 (COC 1/6/97)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3.0'
feet
Material of construction:
® cast iron ❑ 40 PVC El other(explain):
Distance from private water supply well or suction line: N/A: town water> 10' awa
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
There were no observed signs of backup or leakage within the cellar at the time of the field
inspection.
Septic Tank(locate on site plan):
Depth below grade: Top and outlet: 24". Inlet cover: 4"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000-Gallon (H-10) .
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5' L X 4.8'W X 47.5"flow line
Sludge depth: 5
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 119 Augusta National Drive Cummaquid, MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owners Name
information is
required for every Orleans MA 02653 November 19, 2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance
ce from top of sludge to bottom of outlet tee or baffle 28
11
Scum thickness
<1"
Distance from top of scum to top of outlet tee or baffle 7-1
Distance from bottom of scum to bottom of outlet tee or baffle
14" -
How were dimensions determined? measure tape and sludge judge.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The liquid level was observed at the PVC exit line pipe invert. The outlet side of the tank contains a
side exit PVC tee (pre-existing concrete tee is attached at exit wall). The inlet portion of the tank
contains a precast concrete tee. There were no observed signs of backup or leakage within or above
the tank at the time of the inspection. The septic tank did not require routine maintenance pumping at
the time of the field work.
r
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Augusta National Drive, Cummaquid MA Assessor's Map- 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owners Name
information is
required for every Orleans MA 02653 November 19, 2010
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•09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 119 Augusta National Drive Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owners Name
information is
required for every Orleans MA 02653 November 19, 2010
page. City/Town 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
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D13-3/1-1-10. Surface to top/cover: 31". The box contains one inlet line and one outlet line (both lines
are PVC). The unused pipe knockouts contains plastic caps. There were no observed signs of solid
carryover, leakage, backup or breakout within or above the box at the time of the inspection
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System SAS locate on site Ian excavation n
p y (SAS) ( p of required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
119 Augusta National Drive, Cummaquid, MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Mana ement(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is required for every Orleans MA 02653 November 19, 2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑. leaching trenches number, length:
❑ leaching fields number, dimensions:
El 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.):
Surface to top/cover of pit: 34". Surface to floor of pit: 106". The pit is pre-cast concrete. The pit was
measured at 6.0'wide and had a 4.5' effective depth as measured below the inlet line pit invert. The
interior pit perforations were observed to contain crushed stone. Grond probing indicates 2'+ of
stone.The interior of the pit did not contain any standing liquid. Sidewall staining indicators were
measured at 2.3' above the pit floor. Faint or inconclusive markings were observed 3.2' above the pit
floor. There is greater than 6.5"from the inlet line invert to the nearest possible stain line. There
were no observed signs of backup, breakout or hydraulic failure within or above the SAS at the time
of the field inspection.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer '
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Augusta National Drive Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is
required for every Orleans MA 02653 November 19, 2010
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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 119 Augusta National Drive Cummaquid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owners Name
information is Orleans
required for every MA 02653. November 19, 2010
page. Citylrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
L❑CATI❑N A B
TANK IN 25,0 14,4
TANK OUT 29,0 20,0
DIST, BOX 22,7 27,7
LEACH PIT 22,3 42,6
o.
WOOD B
DECK
A
30.0'
119 Augusta National Drive
i
Q w
3
w i
a'
Q
12:1
- w
Q
a_
AUGUSTA NATIONAL DRIVE
FLOOR PLANS JUDD SEPTIC.SERVICE
' Rick Judd, R.S.
1� P.O. Box 1315
LOCUS: _119 Augusta National Drive Harwich, MA 02645
Cummaquid, MA `r.,4 ': ' 508-896-9316
PREPARED FOR: Betty White MAP: 355 PARCEL:009
JOB NUMBER: 10-1 12 SCALE: 1 n = 20'
DATE: 1 1/1 9/1 0 SHEET: 1 Of 17
10 2008 Richard Judd Registered Sanitarian
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Augusta National Drive Cummaguid, MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is required for every Orleans MA 02653 November 19, 2010
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >4.0' below SAS floor.
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:
Al W 247 Zone C on October 2010 at 23.1 = 3.2' adjustment factor.
You must describe how you established the high ground water elevation:
A hand boring/auger hole was conducted to a depth of 7.6' below the floor elevation of the leaching
pit. No groundwater was encountered in the auger boring. The October 2010 adjustment factor was
applied {7.6' -321 for a 4.4' dry adjusted separation distance below the floor of the SAS.
Method 2: Approximate surface elevation at SAS: el. 52.0. Estimated floor of SAS: el. 43.2. Open
Water Body (Long Pond > 200'from pit) to East of locus location at approximate el. 24.0. Estimated
depth below SAS floor to Long Pond surface elevation = 19'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Augusta National Drive, Cummaguid MA Assessor's Map: 355 Parcel: 9
Property Address
Betty White Trust C/O Cape Cod Five Trust&Asset Management(Kristin Perkins): P.O. BOX 20
Owner Owner's Name
information is required for every Orleans MA 02653 November 19, 2010
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. e _ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Zigpaar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System individual Components
Location Address or Lot No. Ow er's Name,Address and Tel.No.
i I v y US
i-h (, 3c,rr�
Assessor's Map/Parcel
Installer's Name,Addres , d Tel.No. Designer's Name,Address and Tel.No.
�,S'SA l
IF
Type of Building:
Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder( �
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is d by this oard I Mo I��
Signed �. ® Date
Application Approved by 1 Date
Application Disapproved for the ollowing reasons
Permit No. y Date Issued
eL-p
iANo. ?..._�.� Fee� I
` — `l
. .. - THE COMMONWEALTH OF MASSACHU TTS Entered m computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
3pprication for Digoml 6pgtem Congtruction Permit
Application for a Permit to.Construct( )Repair( )Upgrade( )Abandon( ) O Complete System 0/individual Components
Location Address or Lot No. Ow er's Name,Address and Tel.No.
l 15 A v y US
�n�t(, At- &1 - �j3c� 'Un
Assessor'sMap/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(NL�
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) A J d e K e �S�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is d by this Board
Signed ` A & Date �a ao A&
Application Approved by do Date
Application Disapproved for the following reasons
Permit No. r Date Issued
t
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (1/)Upgraded( )
Abandoned( )by o`h r-. CVO N
at ha b n constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer SC6`k f— Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date 7 _ f ` l 1 Inspector 'S`
------------------------------------
No. l!✓ ' Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Digpogal bpgtem Congtruction Permit
Permission is hereby granted to Construct( )Re air grade( _),An( ) /
System located at \ U S �l Can.`�, V c' cut--`r^- Uk U
f
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
0 �
Provided:Construction mus k coto within three years of the date of e
Date: Approved by /V ✓ '
TOWN OF BARNSTABLE r
LOCATION n L SWAGE #
VILLAGE (nk ASSESSOR'S MAP&LOTiirr OD 9
INSTALLER'S NAME 8c PHONE NO.
SEPTIC TANK CAPACITY GSC
LEACHING FACILITY: (type) (G.Clg V i-- l x i 5A (size)
NO.OF BEDROOMS
BlALDER OR OWNER Qyf r� UCU
aPERMTTDATE: I ao I NO COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) AA Feet
Edge of Wetland and Leaching Facility(1f any wetlands exist
within 300 feet of leaching facility) I Feet
Furnished by
t
J i
L° A9 �-
TROY WILLIAMS �, a
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection y 2 1 (508) 385-1300
19 Hummel Drive �y � 99�;
South Dennis, MA 02660
L q
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Wllllam F.Weld Trudy Core
Governor - so-tary
ArW Paul Celluccl David B.Struhs
LL Governor romm wbner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION
property Address: �l 9 •/ � �-� !x`�ti S �u fv�L. 2 �• ��J✓��.
Pe Y A y s Address of Owner. f 7a•' L
Date of Inspection: 6 (If different) n
Name of Inspector—/,,yy ; c.
Company Name,Address and Telephone Number.
S" A6o�< , ass ys
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signs Date—
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
_ZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES: N 44
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
Indicate yea, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined',explain why not)
The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or exfrltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
q A CERTIFICATION (oontinued)
S �Property Addre" / ,�}v y J 7L
Owner.
Date of Inspection: V
�a �s / 5G
B] SYSTEM CONDITIONALLY PASSES (continued) ^1/1q
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Boatel of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V/-1
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment. .
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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.
3) OTHER
I
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL 9Y9TEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address ��•�s TK �c+• -1��. t�
Owner.
Date of Inspection:
1p2�S l yG
DI SYSTEM FAILS: f //�
I have determined that the rystem violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded o
cesspool. r clogged SAS or
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 M day flow.
Required pump more than 4 times� m8 in the last year NOT due to clogged or obstructed pipe(a).
Number of times pumped
_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public
water supply well)
The owner or operator of an such m s _y syste hall bring the m and facil
ity ilr into
h' full compliance with the d requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the De (fin °°star treatment program
partment for further information.
(revised 11/03/95) 3
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addnese: / °/ /g✓y ✓S rs. /��� f', a aa�
Owner. 00r7D L'
Date of InspeoUon: !2 /S 1 y 6
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
✓� ayes �; �� /��; us e-
__V/None of the system components have been pumped for at least two weeks and the system has been receiving
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
N/As built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
, The system does not receive non-sanitary or industrial waste flow
_The site was inspected for signs of breakout.
V All system components, excluding the Soil Absorption System, have been located on the site.
f ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
/approximated by non-intrusive methods.
i/ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: i 19 119 ay✓s AAA
Owner. p✓g,� h
Date of Inspection: 0 `
RESIDENTIAL FLOW CONDITIONS
Design flow:3—i-0—Zallons
Number of bedrooms: .3
Number of current residents: 0
Garbage grinder(yes or no): �f
Laundry connected to system(yes or no):,�F 5 -
Seasonal use(yes or no):-LLc
Water meter readings, if available:
Last date of occupancy: Cn C 4 H T (:2 r 1 W r
COMMERCIAL(INDUSTRIAL•
Type of establishment:
Design flow:-------gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5.
system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Lest date of occupancy:
GENERAL INFORMATION
PUMPING-RECORDS and source of information:
System pum as part of inspection: (yes or no)_A/U
If yes, volume pumped: gallons
Reason for pumping.
TYPE F SYSTEM
�— Septic soil absorption system
Single owspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previoua inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if)mown) and source of information: _6,- i •. 4 -AD o „h
.14
Sewage odors detected when arriving at the site: (yes or no) A/o
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address 1 ///9
Owner. Ttl h
Date of Inspection: / 6
SEPTIC TANK-
(locate on site plan)
Depth below grade:
Material of construction: ✓concrete_metal_FRP_other(ezplain)
Dimensions: s X ti X /d d U PC, /o" •
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:_�y
Scum thickness: 111,
Distance from top of scum to top of outlet tee or bailie:
6 "
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stntctural integrity,
evidence of leakage, etc.) C. 74f]2�- i c dt a.t o'�j 4-1 t. A j ,,a d ; .�
W,>r v r p( c r . S . c. r 7' Q. o ,r
69LL L
GREASE TRAP: /g
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(ezplain)
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bade:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address
Owner.
Date of Inspectlon:
TIGHT OR HOLDING TANK/ 1
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity:_ gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: //5
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level an4 distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
.1c 7� ✓.. r.(
PUMP CHAMBER: N 1-9
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7 €_ .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SAY/STEM INFORMATION(oontinued)
G
Property Add., I' 1 ,�+y s / f7"`' 'r-
Owner. -
Date of Inspeotion: / 9 6
SOIL ABSORPTION SYSTEM (SAS):
_z
(bcate on site plan, if Pots)ble;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number: 0(—� 011 7/,.J Q
leaching chambers, number._
leaching galleries, number.
leaching trenches, number,length:
leaching fields, number,dimensions:
over low cesspool, number:
Commentf: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Jo
_ iwj c. jr C a J
.S L[x l� L. LL.,.i (r
L
Or f7rLr` V c Si O li c
CESSPOOLS c.J G r< y✓( t, `SG/ �j`G ��
(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:
in1low(cesspool must be pumped as Part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments: (note condition of soil, sign of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
x If. _IFy�,Ai
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -L
PART C
�t
,, / SYSTEM INFORMATION (contlnuecl) f°
Property Address: y y S /V "�'
Owner. ;
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
6, h .
------------
vi
1 54-
DEPTH TO GROUNDWATER
Depth to groundwater. -feet adjusted high groundwater Iced
method of determination or approximation: U: S u, 1: 11�' 4-6 w w Y
'L - ti i Cis • J v. -T.: _�• / ,. G.r.'.
Cy ;S GC-
ltiJl1� a•�
a
TOWN OF BARNSTABLE r(
3 `o
LOCATION n e\ U SEWAGE #
VILLAGE M!21 n �.t _ASSESSOR'S MAP& LOT Z i r Oy
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY JcQ0 Cry n
LEACHING FACII.TTY: (type) L cGQ,,- 1�l`kr ��c i S (size)
NO.OF BEDROOMS ®v Q`�tS
BUILDER OR OWNER �L r 0Q rU C/\
PERMIT DATE: '1(0 COMPLIANCE DATE: I I Lei GI
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �� Feet
Private Water Supply Well and Leaching Facility (If any wells exist /f
on site or within 200 feet of leaching facility) �Jt't Feet `
Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �Jk Feet
Furnished by
�s
D-9dl,
I
TOWN OF BARNSTABLE
LOCATION I 1 2 � �`/ �'ham+N l �°'>SEWAGE#
VILL,GE ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: ,
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�'s