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Rt f ,., r. ,,,, r s.. •. .. d S't •� - 4y.1 r#K' % r:.:i.�i' z' 1t'.'..4 J, -f`.iu -''• _ , '+a •.. :t T' F.G; y. �.. ..�'.s t P' '� ro ,t y +,- a' �^. av,• - .:zt r £...:4 `"4 S �..i.. to r�f •t f•� J t - �;f - is 1 D�. r 5 , _ i!!�; * S ,l ♦<A!, • ," - +a•`a1.t' ,•'• _ '� � , iv f.�y wr r"t • .. ;[ . a ., o r. ri 1�: TOWN OF BA/RNSTABLE Q I JCATION `I "Na-C IC�G k- L y, S # Y►S 9 VILLAGE N ASSESSOR'S MAP&PARCEL fNSW*kkBWS NAME&PHONE NO. Y IC 0w A SEPTIC TANK CAPACITY �Sd LEACHING FACILITY.(type) � � (size) NO.OF BEDROOMS OWNER (,CA PERMIT DATE: C DATE:�i1 l I7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 r f ! f f f f f f I. 1 f J ! ! / / f ! ! / / 4 \ ♦ \ \ \ \ \ h f J / / f F i J / / I. f f I. 1 4 h \ ♦ 4 \ \.\ 4 4 4 4 4 4 4 4 4'4 n 1 f f f J 1 i J f J f J J i f i J F f J J J - J f f f f J•1 4 \ 4 \ \ f f f f f \ 4 k .24 - 38 { 1 f f J / J f f f f4 J4/4!\f4 f•J4 J♦f 4 h \ ♦ 4 h \ ♦ \ 28 fffllJf <Y 3t •7 ;IN Commonwealth of Massachusetts au7 0* Title: 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments lug 34 Black Duck Lane Property Address John Lake Owner information is Owner's Name required for every Walt Barnstable 02668 Cityrrown Ma 10/17/2017 page. 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. Imngoutf When A. General Information filling out forms a tlon on the computer, a(0(.� use only the tab Inspector: key to move your cursor-do not Chad Hathawa use the return key. Name of Inspector H.P.S. Q Company NaIf me P.O.Box 151 �I Company Address Forestdale Ma City/I own 02644 774-274-2581 State Zip Code Telephone Number 12866 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:- E] Fails ❑ Needs Further Evaluation by the Local Approving Authority in or's Signatu 10/17/2017 Date The system inspector shall su it a co of Health or DEP)within 30 -- this inspection report to the Approving Authority(Board completing Phis 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Uf Title 5 Official Ins ecti Subsurface Sewage Disposal System Form-Not f°n Form Voluntary Assessments 34 Black Duck Lane Property Address Owner John Lake Owner's Name information is required for every West Barnstable Ma 02668 10/17/2017 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: Septic is functioning as designed. Tank in good condition. Tees in place tank level is at bottom of outlet pipe. DBox has small amount of carry overs in dbox. No high staining to indicate box has ever been overfull. Leaching chamber was located and cover was opened. The water level at time of inspection is 11"deep. Chambers are half full. Chamber was mirrored with light no staining on concrete over current water level to indicate historic failure. Sewer camera was lowered into chamber and screen was photographed showing clean chamber sidewall and clean stone in chamber openings above current water level. photos have been summited with report to all parties involved with inspection per request of homeowner. 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•3/13 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 '( 34 Black Duck Lane Property Address John Lake Owner information is Owner's Name ' required for every West Barnstable Ma 02668 page. City/Town 10/17/2017 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 leve l 'to brokena distribution r bu 0 obstructed iJon box d ted pipe(s)or due to a broken, settled or uneven distribution box. System will ue 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 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water El or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 34 Black Duck Lane Property Address John Lake Owner information is owner's Name required for eve ryWest Banstable page. Citylfown Ma 02668 10/17/2017 State Zi Code P 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 34 Black Duck Lane Property Address John Lake Owner information is Owner's Name required for every West Barnstable page. City/Town Ma 02668 10/17/2017 B. C State Zip Code Date of Inspection erti>�cation (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 a nitrogen and nitrate nitrogen is equal to or less than 5 m provided that no other failure criteriapp ' are triggered.A and chain of custody must be attached to this form.] copy of the analysis ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,.you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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 system in accordancepg a the with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ur 34 Black Duck Lane Property Address John Lake Owner information is Owner's Name required for every West Barnstable Ma 02668 page. Cityfrown 10/17/2017 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System F -Not for Voluntary�®r� luntary Assessments •'� 34 Black Duck Lane Property Address John Lake Owner Owner's Name information is required for every West Barnstable page. Cityrrown Ma 02668 10/17/2017 State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 00 0 1 S ors t1` �g D �c6&I'L , -- Sump pump? ❑ Yes ® No Last date of occupancy: Date i 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Black Duck Lane Property Address John Lake Owner Name information is Owner's required for every West Barnstable page. Citylrown Ma 02668 10/17/2017 Zip-Code D. System Information (cont.) State Date of inspection Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: homeowne said tank has been pumped a couple times 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•3/13 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 34 Black Duck Lane Property Address John Lake Owner owners Name information is required for every West Barnstable page. CitylI own Ma e 02668 10/17/2017 Zip Code Date of Inspection D. system Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: V4" feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 30+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 216" feet Material of construction: ®concrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 6e t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �- 34 Black Duck Lane Property Address John Lake Owner information is Owners Name required for every West Barnstable Ma 02668 10/17/2017 page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2811 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 41' Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? 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.): tees in place no visable cracks or leaks. Recommend pumping septic tank every 2 years under normal usage to protect leaching from over loading of grease and sludge Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El 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•3/13 Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection I=ry Subsurface Sewage Disposal System FForm-Not for Voluntary Assessments M r 34 Black Duck Lane` Property Address John Lake Owner 's information is Owner Name required for every west Barnstable Ma 02668 page. CitylI own 10/17/2017 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Ins e or ction F Subsurface Sewage Disposal System F� Not for Voluntarym Assessments 34 Black Duck Lane UW e Property Address John Lake Owner information is Owner's Name required for every West Barnstable Ma 02668 page. citylrown 10/17/2017 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.):. Dbox camera inspected liquid level at bottom of invert Light carry oven;from tank. in normal operating condition 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.): "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: leaching chamber opened. current level is 11"of water in bottom of chamber. no sidewall staining above current level to indicate a historic failure. see Pictures attached to report. t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 34 Black Duck Lane Property Address Owne John Lake s Name inform r ation is owner required for every West Barnstable Ma 02668 page. City/Town 10/17/2017 State Zip Code Date of Inspection D. System Information (Copt.) Type: ❑ leaching pits number. ® leaching chambers number: .4)500 gallon L.0 ❑ 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.): current liquid level in chambers is 11"deep no sidewall staining above current level to indicate historic failure. Pictures were taken and summited with report showing clean sidewall above current li uid level Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration De pth_top of liquid to inlet invert i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction t5ins•3/13 Indication of groundwater inflow ElYes ElNo Title 5 Official Inspedon 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 lug 34 Black Duck Lane Property Address Owner John Lake Owner's Name information is required for every west Barnstable Ma 02668 page. City/Town 10/17/2017 coon Pe D. System Information (cont.) State Zip Code Date of Ins Comments(note condition of soil, signs of hydraulic failure, level of ponding, co etc.): ndition of vegetation, 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-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System F�-Not for �®r� Voluntary Assessments °rt 34 Black Duck Lane Property Address John Lake Owner 's information is Owner Name required for every West Barnstable page. C►tylrown Ma 02668 10/17/2017 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 where public water supply enters the building. Check one of the boxes below: feet. Locate ® hand-sketch in the area below ❑ drawing attached separately t r At A 3 3 ' Q � S�s, 0 � �) 93 fir, 37t 3 OY� � a�1 !Sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System%Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 34 Black Duck Lane Property Address John Lake Owner information is Owner's Name ' required for every West Barnstable page. Cityfrown Ma 02668 10/17/2017 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: 30+ 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: GIS mapping You must describe how you established the high ground water elevation: Perc test results per plan no G/W at test hole. Town GIS mapping area of septic el. 54 Low area at abutters el. 13 Wetland area t5ins•3/13 a Before filing this Inspection Report,please see Report Completeness Checklist on next page. Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Black Duck Lane l Property Address John Lake Owner Owner's Name information is _ required for every West Barnstable Ma 0266g page. City/Town 10/17/2017 State Zip Code Date of Inspecti E. Report Completeness Checklist on ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 't Y Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Black Duck Lane P d-3q—t7 © 9-0o?- M Property Address Lake Owner ame information is t Ow F required for P Barnstable MA 02668 April 17, 2012 every page. ityrrown 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: A. General Information a When filling out forms on the I computer,use 1. Inspector. - only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector _ use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road - Company Address Marstons Mills MA 02648 'B"01 City/Town State Zip Code.. 508-428-1779 S1 12855 Telephone Number License Number B. Certification h.1 I certify that I have personally inspected the sewage disposal system at this address and that tH information reported below'is true, accurate and complete as of the time of the inspection. The Aspecti n was performed based on my training and experience in the proper function and rri6iienance of on site3 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 F� a ❑ Needs Further Evaluation by the Local Approving Authority April 17; 2012 . Job# 12-64 In pector's Signature Date 4 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 p Y the same or different conditions of use. t5ins�11/10 Tille 0 ' at Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I V Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April 17, 2012 required for P every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: Tank was scheduled for pumping following inspection. Leaching system showed no signs of surcharge or saturation. 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•11/10 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 w 34 Black Duck Lane Property Address Lake Owner Owner's Name information is required for West Barnstable MA 02668 April 17, 2012 every page. City/rown 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 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;-Page 3 of 11 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April 17, 2012 required for p every 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 day flow 15ins•111110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 Aril 17 2012 required for p , every page. Cityrrown 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 groundwater 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA - 02668 Aril 17, 2012 required for p 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 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 w ' 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 Aril 17, 2012 required for p every page. City/Town State Zip Code Date of Inspection D. System Information } Description: Number of current residents: 2 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)): Detail: Sump pump? r ❑ Yes ® No Last date of occupancy: Currently Occupied. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is p required for West Barnstable MA 02668 April 17, 2012 every 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: Last pumped 11/24/09 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 i ❑ Tight tank. Attach a copy of the-DEP approval. ❑ Other(describe): t5ins•11/10 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 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April required for pil 17, 2012 every page. City(Town State Zip Code Date of Inspection D. System Information (cont) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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: 2 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 4" t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April 17 required for p �il , 2012 every page. Cityfrown 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 28" Scum thickness 4 6„ Distance from top of scum to top of outlet tee or baffle , Distance from bottom of scum to bottom of outlet tee or baffle 101. How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank was scheduled for pumping following 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-11/10 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 34 Black Duck Lane Property Address Lake Owner Owner's Name information is west Barnstable MA 02668 Aril 17, 2012 required for p every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 15ins-11/10 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 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April 17, 2012 required for p every page. City1rown 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 01. 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.): No solids or high stains present, liquid level was at bottom of outlet pipes. 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.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts • Title 5 Official Inspection Form .Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA .02668 Aril 17, 2012 required for _P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Four 500 gal drywells. ❑ 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.): Stone and soils surrounding SAS were probed with no evidence of saturation found. 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 !Sins-11110 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 34 Black Duck Lane Property Address Lake Owner Owner's Name information is west Barnstable MA 02668 Aril 17 2012 required for p every page. Cityrrown 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.): R 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 � Commonwealth of Massachusetts _ 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Black Duck Lane _ Property Address Lake Owner Owner's Name information is required for West Barnstable MA 02668 April 17, 2012 ------ — every page. City(T'own 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 24 .� 38 , \ \ \ \ . 5 \ \ , 28 9 1�j • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April 17, 2012 required for every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar, ® Shallow wells Estimated depth to high ground water: 15+ 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: Low point at rear of property is considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-11/10 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 34 Black Duck Lane Property Address Lake Owner Owner's Name information is West Barnstable MA 02668 April 17, 2012 required for p every page. Cityfrown 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 " A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 -77 TOWN 3-11 OF BARNSTABLE A�o LOCATION 14, SEWAGE # VILLAG ASSESSOR'S MAP & LOT as INSTALLER'S.NAME&PHONE No. Y--,E3, SEPTIC TANK CAPACITY LEACHING FAciLrry: (type) ,ADO 7-7 41 k 14 L.L6 ize aL X13 NO.OF BEDROOMS_��' BUILDER OR OWNER QG 4,Gso PERMIT DATE: COMPLIANCE DATE: Separation,Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If anywetlands exist within 300 feet of leaching facility) Feet Furnished by . ......... ry Lv W TOWN OF BARN STABLE q / e LOCATION 3� ` SEWAGE # l Tp Z y( {` � �� V17.LAGE ASSESSOR'S MAP & LOT Q,;�2�DD� INSTALLER'S NAME&PHONE NO. 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