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HomeMy WebLinkAbout0028 CAPE COD LANE - Health 2� Cape Cod Lane Bai i astable P A = 298 003 u a II i I t �1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Cape Cod Lane Property Address Brian Cabral .Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab V 1 Inspector: key to move your . I cursor-do not Ricky Wright use the return Name of Inspector key. B& B Excavation,lnc. reb Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails El Needs Further Evaluation by the Local Approving Authority 2 , 5/24/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. (-� I � 1 7V IT t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 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•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 ;M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is 9 required for every Barnstable Village MA 02601 5/23/12 page. City/Town 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: I ❑ 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•11/10 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 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is required for every Barnstable Village MA 02601 5/23/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-11/10 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 M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 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 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 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 II❑ a ,system components, excluding the SAS, located on site Y P 9 . ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 page. Cityrrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: h t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: 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-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 °M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 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: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 1/2' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order- No sign of leakage or blockage. Septic Tank(locate on site plan): 6,1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If.tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 1500 gal Sludge depth: 4" pt t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 page. City/Town 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 34" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound No sign of back-up. 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 M Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.): At time of inspection d-box appears to be in good 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS.not located, explain why: i t5ins•11110 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 M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): At time of inspection leaching appears to be in good condition. No sign of hydraulic failure 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-11/10 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 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsur face Sewa a Disposal System F 9 P y orm Not for Voluntary Assessments �M °y� 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is Barnstable Village required for every MA 02601 5/23/12 page. Cltyrrown 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 7 Al �f. 15,5 t5ins:11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 1.7 f Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is g required for every Barnstable Village MA 02601 5/23/12 .page. Cityrrown 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: >10' 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•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 °M 28 Cape Cod Lane Property Address Brian Cabral Owner Owner's Name information is Barnstable Village MA 02601 5/23/12 required for every page. City/Town 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 I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i a� C', COMMONWEALTH OF MASSACHUSETTS 34��c� EXECUTIVE OFFICE OF ENVIR f / -DEPARTMENT OF ENVIRON WkAA PROTECTION 0, Q)ViS QH TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Z -c,1Pis C,,;,� is Owner's Name: MA(ZK Labrc-J ,PARCEL � Owner's Address:_9 5 i O t O STr4--E (z U ® - --w xteLA(le (4 Date of Inspection: i 2-cO; Name of Inspector: (please print) y AA-rrNE.w C_1-n-D� Company Name: cPsMG Mailing Address: 99 Abbr,--r i ( Telephone Number. (' 08;) (i,49 -( 479 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a.DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes ` Needs Further Evaluation by the Local Approving Authority Fails Inspector's,Signaturel �� �-- Date: The system inspector sball submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/-000 page I Page 2ofil OFFICIAL INSPECTION FORNI-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ;P- cAnc c_ ,,) z—ti Owner: yy1kz (- c'_,/4[z,-,lkL Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _"/ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved'by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If`not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exf ltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)am replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSNIEN'I'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z S C-.�Vc Ica "%jI Sapy 5 L" Owner:Lam' (z4 Date of Inspection: >-i Z-c%'T C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated'wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorptions stem(SAS)and the SAS is within 100 feet a Y of surface water supply or tributary to a surface water supply. _ The system has aseptic 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's*.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ZH -roPc cb o c.:,j, ►�9/LLS'�./��Lc Owner: mo(c(c C„ii3r,,'+L Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No f Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool c/ 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 v Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 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. 11z 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.]'Phis system passes if the well water..analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compozmds 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 S.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] �U (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CNIR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 C�1R 15.304.The system owner should contact the appropriate regional office of the Department. i Page 5 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ZL Cx4ac wG JLf31Z-1%1S I.AF c- Owner: Mor—K uje 4c Date of Inspection: 3--(z ti, Check if the following have been done. You must indicate`yes"or"no" as to each of the following: Yes No MA 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?. i/ Has the system received normal flows in the previous two week period i/ 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) s! _ 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,exchKiing 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 SAS stem location of the Soil Absorption S on the site has been. P Y ( ) n determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of.distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Zit' CA06 c,.:o L,v Owner:Vv\A Cy- CAriz - Date of Inspection: '3—i z-c; FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): >� C.,P6 Number of current residents: z Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):- Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): _71,yoc or,'i = (5 t,l 6-Pb Sump Pump(yes or no): .tic Last date of occupancy: c,joec d+- COMMERCUTA NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): zDd Basis of design flow(seats/persons/sgfr,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancyluse: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 6Ujxte L t �YL AG4 Was system pumped as part of the inspection(yes or no):CU-0 If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping. TYPE OF SYSTEM L/Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system es or no if es attach v' y (y )( y previous inspection records, if any) _Innovative/Alternative technology.Attach a copy,of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 4J� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , Ot C I-Ptf c- Owner: m !'cA 3rR Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 1. Materials of construction:_cast iron ✓40 PVC_other(explain): Distance from private water supply well or suction line:r/j,4 Comments(on condition of joints,venting,evidence of leakage,etc.): A'I Trf SEPTIC TANK: (locate on site plan) v Depth below grade: Material of construction: ✓concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: `yF x� oQ4-y1je-, i c-a L C- Sludge depth: :3' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: y s Distance from bottom of scum to bottom of outlet tee or baffle: t- How were dimensions determined: 34,Jyt j JL!9,9 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): TLk4- eva c:: (9Ak/4(,-E A i' ci'wte 6Njpe��3 ,�! GREASE TRAP:i+11 hocate on site plan) Depth below grader Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): R Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 G (-:,> L 0-1 Owner: r�tr c ti�fn.� t Date of Inspection: TIGHT or HOLDING TANK:0�(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explaiti): Dimensions: Capacity: gallons Design Flow: Rallons/day Alarm present(yes or no): Alarm level: Alarm in worldng order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: 1/ (if present must be opened)(locate on site plan) ' 1. Depth of liquid level above outlet invert: O:c 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.): �.rUISrP�J ( 14) ( +Jv Str,nri o^ ( t�E vP� Sb'uds f��/4�'YC G�4- �,-M2 c,p Iw��'Cf w� PUMP CHAMBER:NO- (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:8 CAPz C iln i. Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number- leaching chambers,number.-2 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.): iel-Ck,+/L--- C4ACM1.e j w i lfiCS�bje i� D/2j CJ1 N:' ail N uL k•j0P4:1t 'C. JZ4 (vYC CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan). Number and configuration: Depth—top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 0 t- Page 10 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIMATION(continued) Property Address:Z Cape- Owner:L11Va/UL Date of Inspection: 3 t 2-off SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Tvi,r,.i 0' a iL s vim, 3 A ( A 2 Gc' = �� A 3 146' r3 t Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: La f; C V;r Owner- (410L Date of Inspection: Z—kZ--o SrTE EXAM Slope P4�- Surface water"f Check cellar izj Shallow wells N� Estimated depth to ground water t�_ feet Please indicate(check)all methods used to determine the high ground water elevation: j ✓Obtained from system design plans on record-If checked,date of design plan reviewed: ,-t Zcvc , 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: ,,Jb & Szj-✓e-f cc, ki='i L.vl 1-0^6 '-'�Z,c,r,e_ -�edtcuU C ._. ��{-�:4-{�-r�N ��j,��N �IQN)�/LJ✓': its iyelJ�:'�h�G`L�:� x 11 , TO11 I-0 VARNSTABLE b _..LOCATIGN ��C �-'� SEWAGE # 96VO-0 S' VILLAGE—��Y �` � ASSESSOR'S MAP & LOT STALLER'S NAME&PHONE NO. II�I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) - (size) NO.OF BEDROOMS ak0L�4000 Af rv�vra.-- 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 CA vr-)6�k k t b r ! 1 N Yt� l 111 No. `Za��e a ���-J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Oigozaf bpztem Construction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 28 Cane Cod. Lane , Barnstable Richard. Lovell Assessor's wp/Parcel .Installer NaT,o Y- onel ge pt i C Service Designer's Name,Address and Tel.No. P 0 Boxtt1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 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 Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system Consisting of a tank, D-box and. 2 leach chambers with stone all around.. 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 issued bytes B d of Signed Date Application Approved by Date ��- ere) Application Disapproved for th follo ing reasons Permit No. Ana y'L; Date Issued l4�.. No. 2aa0 Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ti Rpprication for Migoar *p!Atm Conmruction.permt=t Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 28 Cape Cod. Lane, ' Barnstable Richard. Lovell Assessor's Map/Parcel �d ,�y r .Inistlallereaa O q 1T1S OYTle1 J e pt ,C Service Designer's Name,Address and Tel.No. UP 0 Bok 1089, Centerville i z , Type of Building: - Dwelling No.of Bedrooms 3 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 Sand ( Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system consisting; of a tank, D-box and 2 leach chambers with stone all around.. Date last inspected: - Agreement: "4 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 issued b B of Peallh. Signed ! Date Application Approved by sp Date Application Disapproved for th follo ing reasons Permit No. /boo — Date Issued ---------- ---------------------------- THE COMMONWEALTH OF MASSACHUSETTS Lovell BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned b Wm. E . Robinson Septic Service at 28 Cape y o Lane , Barnstable has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated Installer Wm. E. Robinson S r. Designer The issuance of this permit shall not b f construed as a guarantee that the sys m function a esi -nedw fi Date / ,--. Inspector At$ 71 :. � '4 J --------------------------------------- No. 9,mr7— a� (,/ Fee .5 0 THE COMMONWEALTH OF MASSACHUSETTS Lovell PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0i6poeal )*pgtrem Construction Vermit Permission is hereby&nH ttoeCoa tru. A ,p tSarP3HU�grade )Abandon( ) System located at 3 i 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. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by ly • � �• 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WTTHOUT DESIGNED PLANS) I, William E . Robinson,S1 eby certify that the application for disposal works construction permit signal by me dated �/oil/�� , concerning the property located at 16 Garden Lane , Hyannis meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated wi the dwelling. The soil is classifi as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wed within 100 feet of the proposed sepuc system There are no priv to wells within 150 feet of the proposed septic system There is no i in flow and/or change in use proposed • There are no requested or needed. • The botto of the proposed leaching facility will Mt be located less than five feet above the maxim adjusted groundwater table elevation.f Adjust the groundwater table using the Frimptor meth when appiicablel • If e S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen 114)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using G1S information) .S 0 B) G.W. Elevation +the MAX High G.W. Adjustment. DIFFERENCE.BETWEEN A and B SIGNED ✓� DATE. _ ! G'e—U A (Sketch proposed plan of system on back]. y:healih folder:een ,� I � t -�� �. �-�l � u 1/6/" NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. voy - � CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT[WITHOUT DESIGNED PLANS) -, William E. Robinson,s>:hereby certify that the application for disposal works construction permit signed by me dated 6-0 , concerning the property located at 28 Cape Cod. Lane , Barnstable meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses iated with the dwelling. The soil is assified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within lot)feet of the proposed septic s stern — There are n private wells within 150 feet of the proposed septic system • There is increase in flow and/or change in use proposed • There aI no variances requested or needed. • The bo om of the proposed leaching facility will not be located less than five feet above the max urn adjusted groundwater table elevation. f Adjust the groundwater table using the Frimptor me when applicable[ the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: c � A) Top of Ground Surface Elevation(using GIS information) / L B) G.W.Elevation +the MAX High G.W. Adjustment . = 3 6 d =f DIFFERENCE.BETWEEN A and B SIGNED : � L f, DATE: [Sketch proposed plan of system on backl. y:health folder:cen o f-;. J i -i i ti i I I I' TOM ` P RARNSTABLE LOCATION Wl- CL-?e-(0A SEWAGE # 1.vo-PS y ' I VILLAGE ASSESSOR'S MAP & LOT I i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type). (size) NO.OF BEDROOMS / BUILDER OR OWNER f PERMITDATE: COMPLIANCE DATE: I7'QZ� f 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 f - - I °� i 05/15/2002 11:50 5088217684 HAMMOND DELEADTNG PAGE 01 Dep,& tz mi of*'ubB&$ealdx/De p eni of Labor&Workforce Nvel&pmeat t J i�'S'F3s`Y�t.�'i�t cep�3�2.ElA$7�iG wd31t� � AL aeettmwg of ids£ar'ce mtrat be empIxTed#e<ar@rr is caeg3pYy vPcQ the noVkutim requirmasu ofbLG.L, C.V-191V. 1 454 CrvM2106 and 1.05 CNR 460"btil3.as MM Ffteutbr mended j Ca�ntrastorpe,,:hrmSngpr�ojaet Hammond Deleadix�g l eenee# DC11168 a l3sEo 6-09--0.; 1 ' Lead PaW lsooetQrr o), � _ Dine of aae as f t • .�1�RLS5 O'F P�O��: . 8treas aidre�.a � � °�� .Vt•Xt rbw Der f��-l-gbSP zip `(0 0 — Property•( wIv AA„M ___Adciran Toeepmoue I`uvr+.bes 3)seslluM1 ash GoagLo t C verfty Other it°"C*e?,wems -,please capes Ch=*I,eno..Start r?e?I g is®m�3ts• aIy�:,,,� Sfagie iik�" �_., Dfhe:' CompletirrADa� y� u wffi w �rk be 40-ae: (��$ttaes an szto) `�teasitetttls'� _ Prale.tStpvvUorN 2e Mark �jarrsl?cLOr J Ltae�se# D53229 Date 3-19-0' _ Reliance Si'o:kCei''s�nzngea€afdaxaFa�c3'1'�a�ber -- — - -----e �attra6r YA case of amervmy eon# JG�"� Ramer>ana g� a fl B 8 Z 1•-7 5 8 4 (Cam�racttflr'a y`cepsresant�xt�rveg C e i 1# (5 0 8) 2 d 3-16 6 8 )'31E WONG LmIT'& The undmiaed hereby�V-*•Wider f1t:PZYase and p l�les arperI'ary:ihat�;ge&ea x cad anS,n�vds�rao8 r&a Ca�aou�ih of M ms,t4%u"ttts 1?Prles�i ga(ny ns,454 C 22.00,,and the Lad P018 mmt Lg vend*D and control PREQ10fil ,105 CbM. 46�.. 00,and tlxat the ieOms'e"b"f alned itz t?tis aatiHegtlnu i�t�+ae a eok ev the best ofi ltt�©r t�xa^�1$d�a arnd better Daip CompRnyN:tmu r.1ammor_d Deleading A4a 19 orahaad Street Berkley MA 02779 Teleph�ti© �r� bcr (508) 821--7664 CeI14 (508) 243-1668 OVER-* 07/22/2002 12:44 5088217684 HAMMOND DELEADING PAGE 01 i ������ggb�t:�e�t�kJl��,�x•��n��11;;:�a����r• r�c II+:u����t k the noae4=requbmVMU of MX I—C.111§197, �I Harunond Delead.i,ng Lie. DC1068 -XP.Dxtq 6-09-0; Comm x�r pe�srmiag proj �x —�-�-- Yjead PftTn.t InMqoc;W r s set isdo ` ter t' Apt.Iq'r-u%ber Prfipetu+C3xasr drags 9" _ E TaiapitoueNu trbcriu`_,,.I,4—I T DsWdlaag Mletod- 0 Sa'� eaE Cam. Li rtl mi Ae=o ftiWl i?uts ieS P ni. Covazing C"hba oae: D liva is mats fix.-'?Y — sf ie-f My 5tr Date Mark i�arx�r_gton I�tcenes€_ DS3229 , 3-1.9-0 P�e--i S ntrvisor lvaaece� _ _ __ lA i` Csxxfier Reliance wo*mrls Compews i*71 John Hajj=nd Tel.# �508 82?-"ro'84 It aaso of otx�ergetsr.?•ear.�c�c - (Cosiiradorly Repmentaiive' (5 0 8) 2 a 3-166 8 Ikn.,LI++6,13I��C���ACTt The cmder9lpa heraby Stgtes..under the paime ausl p 3u ',iha't ke,-ire bss rwzfss$ard moal smad i tr CymmIr &2Itb d: assarifuaerax Iaetesz�iri 1�teg�ta x ,45 Cn?t Z2•f!a,and 1te av'eq veudou=a Control i2,qralgfiohs•,105 Clm 4 .il0©,arad taut a i�sibrkn �2�t0ulssinea Sri this as 93 a 'd eez r t 44tfs{itar issavriad a and beiiei: Dos:. � b;L &ice C'amymyNome NaMond Deleading Aft=s 19 Orchhmd Street Berkley IAA 02779 Te�ep�telLa�'�ibe'r (5Gg} 821-7684 /Ce11T (508) 243-1668 OVER-*