HomeMy WebLinkAbout0105 COUNTRY CLUB DRIVE - Health 105 Country Club Drive
z
350-040 Barnstable
Commonwealth of Massachusetts 3�0-Dy�O
Title 5 Official Inspection Forte
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 105 Country Club Dr.
Property Address
William Ricci
Owner Owner's Name ,
information is
Cumma ui p
required for every q d O Al2 l�l�`TX}f3L MA 02675 4/23/2018 '
page. City/Town State Zip Code Date of Inspection 1
Inspection results must be submitted on this'form. Inspection forms may not be altered in any(0
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling out forms �/ # 02 q 7
on the computer, /
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
kee the return - Name of Inspector
Y
Cape Cod Septic Services
rab Company Name
350 Main St
Company Address
reran W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
Telephone Number "license Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in.the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of —~
Title 5 (310 CMR 15.000).The system:
Passes ❑ Conditionally,Passes ❑ Fails
❑. Needs Further Evaluation by the Local Approving,Authority.
4/26/2018
Inspectors 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.
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
�Lo VS
Commonwealth of Massachusetts
-- Title 5 Official `Inspection Form..
a a Subsurface Sewage Disposal System Form -.Not.for.Voluntary Assessments
'r 105 Country Club Dr.
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid MA 02675 4/23/2018 ,
page. Cltylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check AB,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 fail ure`criteria described
in 310 CMR 15.303 or in 310!CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Systems .
mi i. y s n working condition:.
B) System Conditionally Pa
s"ses:'
❑ 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 approve6 by
the Board of Health,,will pass. ti
Check the box for"yes"; "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please eicplain.
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): n
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of.Massachusetts*
- W Title 5 Official Insp action •fF®rm.
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
105 Country Club Dr.
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid MA 02675,=' : . 4/23/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont)
❑ Pump Chamber pumps/alarms not operational. System-will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
Observation of.sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a'broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health); .
❑ broken pipes)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):.
e
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):
El obstruction is removed ❑ Y ❑ N ,A❑ 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(l)(b)that the system is not functioning`in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
105 Country Club Dr.
;IM
Property Address
William Ricci
Owner Owner's Name -
information is
required for every Cummaquid MA. 02675 4/23/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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.
El The system has a septic tank and SAS and the SAS is within a Zone 1:of a public water
supply.
❑ The system has',aseptic,tank and SAS and the SAS is with in'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".
r 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.otherfailure 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
F ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
«M 5••�'•V 105 Country Club Dr.
Property Address _
William Ricci
Owner Owner's Name -
information is "
required for every Cumma uid ,MA
675 02
q 4/2
page. City/Town 3/2018
V State Zip Code Date of Inspection
B. Certification (cont.)
(Yes N
- � Required pumping more
q p p g a 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 Ato 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 supplywell with'no acceptable
p e water qualityanalysis. his
system asses if the
Y IT ,
Y p well water ana
lysis, performed at 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 lie attached to this form.]
The'system is a cesspool serving a facility with a design flow of 2000gpd
10,000gpd. • _ . n
E] ® 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-facllity with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems; you tmu
questions in Section D. st indicate either"yes"or"no".to each of the following, in addition to the
Yes No,
❑ the system is within 400 feet of a surfaceArinking water supply
❑. .❑ the system is'within 200 feet of,a tributary to a surface drinking water
supply
❑ ❑ the system is located in.a nitrogen sensitive area(Interim Wellhead Protection'.-
Area—IWPA) or a mapped Zone 11 of a public water supply well
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.
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Title 6 Official Inspection Farm: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 '+
105 Country Club Dr.
�M y0
Property Address
William Ricci f
Owner Owner's Name
information is
required for every Cummaquid MA 02675 4/23/2018
page. City/Town State Zip Code, Date of Inspection
C. Che
cklist _klist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No •,
® ❑ Pumping information wasprovided'by the owner, occdpant, or Board of Health
® -Were any of the system components pumped out in the previ' -two weeks?
❑' T ® 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 IN they were`not
available:note.as N/A)
® ❑- Was the facility or dwelling inspected for signs of sewage backup?
{
® ❑ 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 CM'R 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):: . 3 i
• ( 9 ) - Number of bedrooms (actual):. 3
DESIGN flow based on 31.0 CMR 15.203(for example: 110,'gpd x#of bedrooms): 110x3=
330gpd
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Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 105 Country Club Dr.
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid MA 02675 4/23/2018
page. Cltyrrown
State
Zip Code Date of Inspection
D. System Information
Description:
1
Number of current residents: 0 -
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 El No
Seasonaluse? Yes ❑ No
Water meter readings,if,available.(last 2 years usage(gpd)): 2016=118gpd
2017=77gpd
Detail:
Sump pump?. El Yes. ® No
Last date of occupancy: Unknown
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?
El Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
G Water meter readings, if available:
t5ins.3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official 4Inspectionorm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Country Club Dr.
Property Address
William Ricci .
Owner owner's Name
information is ~
required for every Cummaguid MA 02675 4/2W2018
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
Y � r
,
I
General Information
Pumping Records:
Source of information: No Records "
Was system pumped as part of the inspection? # x
- ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Truck Glass
Reason for pumping: Maintenance
Type of System:
® . Septic tank, distribution box, soil absorption system
El Single cesspoolf
Overflow cesspool
❑ Privy'*, ..
Shared system s(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): z
l5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
M --- W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Country Club Dr.
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid MA 02675 4/23/2018
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: ..
Were sewage odors detected when arriving at the site? ❑ Yes ®. No
Building Sewer(locate on site plan):,'
Depth below grade:
feet r
Material of construction.,
❑cast iron ®40 PVC ❑ other(explain): '
Distance from private.water supply well,or suction line: ' +10' `
feet
Comments (on condition of joints, venting,•evidence of leakage, etc.):
Line was checked with sewer camera'and found to be clean, properly pitched with no sign of root
intrusion:
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
_ . . ® concrete '
metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate f y of Compliance? (attach a copy of certificate) -❑ Yes. ❑ No
y Dimensions 1000GaI
: � _
Sludge depth: 8-10
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
N_ v Title 5 Official .Inspection Fo' rm x.
a Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
105 Country Club Dr..
Property Address,
William Ricci
Owner Owner's Name
information is C
required uir ed for eve
ry
um m a uid-
, MA
02
page. City/Town 675 , 4/23/2018
.=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
Scum thickness 2-3"
Distance from top of scum to to of outlet tee or b f
baffl p e
Dist
ance from bottom of scum:.ao bottom of outlet tee or baffle
-How were dimensions determined? '
Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle cond'ition,.structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good structural condition:-PVC tees in place. Tank at normal operating level.Tank
was serviced.
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
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Title 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official 'Inspection Po''r,m ,
a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Country Club Dr.
Property Address
William Ricci - g>
Owner information is Owner's Name _
required for every Cummaquid MA 02675 4/23/2018
page. Cityrrown 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 ❑ meta ❑fiber lass
• - l 9 ❑ polyethylene'. ❑ other(explain):
------------------
Dimensions:
E
Capacity:
gallons
Design Flow: r
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
b
t5ins•3113
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts . t
Title 5 Official Inspection Form:
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
105 Country Club Dr.
Property Address
William.Ricci
Owner Owner's Name
information is
required for every Cummaquid MA 02675 " 4/23/2018
page. _ City/Town State Zi Code;
P 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 , 0i
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
,x ,etc.):
: -
H-10 DB-3 with 1 line in and 1 line out in,good condition. Box is.clean and-level with minimal solids
carryover. No sign of overloading or hydraulic failure. Cover 6"below grade.
fr r r r •
Pump Chamber(locate on site-plan)
Pumps in working order: ❑` Yes ❑ No*
Alarms in working order: ET 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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts` _
W Title 5 Official -inspection Form i
Subsurface Sewage DisposaUSystem Form -Not for Voluntary Assessments
105 Country Club Dr.
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid. MA 02675 4/23/2018~ -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-64
❑ leaching chambers number:
El 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,1evel of ponding, damp soil;condition of
vegetation, etc.):
1-6x6 Pit with stone. Pit was found dry during inspection with no evident staining: No sign'of
overloading or 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
N - i
Indication of groundwater inflow ❑ Yes ❑ No
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form =
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
c' M 105 Country Club Dr.
Property Address ,
William Ricc
i
Owne
r O ,
wner's Name _
information is Cumma uid
required for every q MA 02675 4/23/2018
page. City/Town
• e Zip _
p-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.):
{. e
T
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection
.Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Country Club Dr. - -
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid MA 02675 `4/23/2018
page. City/Town State ; Zip Code Date of Inspection
D. System Information'(cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building: Check one of the boxes,below:-,
❑ hand-sketch in the area below,
® drawing attached separately . d
t5ins♦3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17'
Commonwealth of Massachusetts
Title 5 Official lftpection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
105 Country Club Dr.
r.
Property Address
William Ricci
Owner Owner's Name
information is
required for every Cummaquid -MA 02675 . r
page. City/Town 4/23/2018
State Zip Code Date of Inspection
D. System-Information (cont.)
Site Exam:
Check Slope
® Surface water,
® Check cellar
I
® Shallow wells
Estimated depth to high ground water: +13'
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)
El Accessed USGS database explain:
"
You must describe'how.you established the high9ground water elevation: ;
Hand auger 4' below bottom of dry pit with no water encountered. Bottom of pit at 9'.
----------------
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113
Title 5 Oficlal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
P
Commonwealth of Massachusetts
w Title 5 Official-Inspedtion Form" .
Subsurface Sewage,Disposal System Form -Not for.Voluntary Assessments
° se' 105 Country Club Dr. .'`
Property Address
William Ricci .
Owner Owner's Name
information is
required for every Cummaquid ;MA 02675 4/23/2018
page. City/Town State 'Zip Code Date of Inspection
E. Report Completeness Checklist.
® Inspectio' mSummary: 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
t
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Page 1 of 2
I i wN yr BAKNN IAUL r
LOCATION s" CLA, di I, SEWAGE M
Vud:AGE I AM Sk6�
ASSESSOR'S MAP&LOT
3S8 OLIO
INSTALIFR'S N4NM&PHONE NO..
I SEPTIC TANK CAPACITY . I UifO
t
LEACMG mcmrry:(type) r?,r t x6 (size}
NO.:OFBEDROOMS�_
BUILDER OR OWNER diAre f S
PER141TDATE. - -- COMPLIANCE DATE
Separation Distance Betureen"the:
Maximum Adjusted Groundwate;Table to the Bottoth of Leaching Facility Feet`
Pn ate Water Su Pl 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 leas ' g facilily Feet
Fumished by` e1.!•d'et. In
t
.1 F
6 GAfA'6c-
Y
�rpAT
FOT
'c a0 4ia
y. O ,e 3 so
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar--350040&seq=1 . 4/20/2018
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL,PROTECTION
C)
r— c� �
m TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS'. SSMETS Y
�-+ _ (P
SUBSURFACE SEWAGE DISPOSAL SYSTEM FO
PART A co
r\.) r
CERTIFICATION
Property Address: 105 Country Club Drive
Cummaquid. MA 02637 O
Owner's Name: Jay Diston
Owner's Address:
• ��7 g
Date of Inspectiom October 19J006
Name of Inspector: (Please Print) Janes M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Ostervft MA 02655-0049 -
Telephone Number: (508)862-9400 ,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my.
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes -
Conditionally Passes
e ds Further Evaluation by the Local Approving Authority
ai
Inspector's Signature: Date: October 23,.2006
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or.
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow.of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be-sent to the system-owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Cormnents Septic System is in part of the driveway. Discussed with owner.about not driving over it or
installing a berm to stop vehicles.
****This report only describes conditions at the time of inspection and under the conditions of use at that-
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
r /15/2 page
.Title 5 Ins ection Form 6 000 1
P. - p g _
Page 2 of 11 ;
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) 4
Property Address: 105 Country Club Drive t
Cummaguid MA
Owner: Jay Diston
Date of Inspection: October 19, 2006
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:
�k
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If not determined ,please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank.failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available..
ND explain:
Observation of sewage backup or break out or.high static water,level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
r ,
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced.
ND explain:
The`system"required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval ofthe Board of Health):
broken.pipe(s)are replaced
obstruction is removed
ND explain:
2
• k
I ti e
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Country Club Drive
Cummaquid, MA
Owner: Jav Diston
Date of Inspection: October 19, 2006
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:
privy or Cesspool ri is within 50 feet of a surface water
p P
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a'septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water.supply,well. ,
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more 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 colifonn
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: F
3 ,
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM•INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Country Club Drive
Cuniniaguid, MA
Owner: Jay Diston
Date of Inspection:ection: October 19 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well.is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as '
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System: .
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-IW_ PA)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.
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 105 Country Club Drive
Cummaquid M,4 ,
Owner: Jay Diston
Date of Inspection: October 19, 2006
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)o0he site has been determined based on:
Yes No
✓ Existing information: For example,a plan at the Board of Health. ,
✓ Determined in the field(if any of the failure criteria related to Part C.is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5 .
Page 6 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 105 Country Club Drive
Cunimaquid, MA
Owner: Jay Diston
Date of Inspection: October 19, 2006
FLOW CONDITIONS ...y
RESIDENTIAL
Number of bedrooms(design): '3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): - 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection.required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL. ,
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd, '
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
{
,GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 1999-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was.quantity pumped determined?
Reason for pumping: `
TYPE OF SYSTEM
- Septic tank,distribution box,soil absorption system ,
Single cesspool
Overflow cesspool `
Privy
Shared system(yes or no) (if yes,'attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner_)
Tight Tank. Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 4130180-per as built card
Were sewage odors detected when arriving at the site(yes or no): No -
6 .
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 Country Club Drive
Cummaquidd, MA
Owner: Jay Diston
Date of Inspection: October 19, 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC, other(explain):
Distance from private water supply well or suction.line:
Comments(on condition of joints,venting,evidence of leakage,etc.): `
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
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: 1000 gal:
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring 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.):
Cement tees were present. The liquid level was even with the outlet invert There did not appear to be anw signs of leakage
The tank is in the driveway(see front page).
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: concrete _metal fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,-structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) ,
Property Address: 105 Country Club Drive
Cuniniaguid
Owner: Jay Diston
Date of Inspection: October 19. 2006
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and clean. No solids were present The D-box is in the drivew (see front page)
PUMP CHAMBER: None (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.):
M
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 Country Club Drive
Cunnnaauid. MA
Owner: Jav Diston
Date of Inspection: October 19. 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
9 )
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'(1000 aY�_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
Innovative/alternative system• Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The leach nit was dry. The scum line was approximately 4'up from the bottom There did not appear to be any s_ inns of failure.
A video camera was used to perform the inspection The pit is in the driveway(see front page)
CESSPOOLS: None (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: None (locate on site plan)
Materials of construction;
Dimensions: _
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
• Page 10 of 11 M
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART:.0 . `
3 SYSTEM INFORMATION(continued)
a
Property Address: 105 Country Club Drive
Cummaguidr MA Aq*
Owner: Jay Diston
Date of Inspection: October 19, 2006`
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`supplysriters the building. _
1 a0
i
.r f .3 ,A xs rP•.^.S c .¢ ;F'fpe � T. .a
e L u
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Country Club Drive ,
Cuninsaguid, MA
Owner: Jay Diston
Date of Inspection: October 19, 2006
. s.
SITE EXAM ='
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to'determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board ofHealth-explain:topographic and water contours naps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topogrphic[naps and water contours maps, the maps were showing approximately 30'+/-to ground water
at this site.
This report has been prepared only for the septic system and components described herein: This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
' I1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
JUN U 2 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT. -
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS i
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 10 Country Club Drive
Cummaquid, MA 02637
Owner's Name: Margaret Spatz MAR
Owner's Address:
PARCEL L �
Date of Inspection: May 17, 2004 LOT
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the.Local Approving Authority
Fails
Inspector's Signature: Date: May 19,2004
The system inspector shall submit.a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title'5 Inspection Form 6/15/2000 page I
Page 2 of 1 I
OFFICIAL INSPECTION FORM - NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Country Club Drive
Cummaguid, MA
Owner: Mar aret Spatz
Date of Inspection: May 17, 2004
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 exfltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Country Club Drive
Cummaquid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
,Cesspool or privy is within 50 feet of a bordering vegetated wetland.or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Country Club Drive
Cummaguid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ 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 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 forma
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
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 or
the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 105 Country Club Drive
Cummaauid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
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:
Yes No
✓ _ Existing information.. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]. ,
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 105 Country Club Drive
Cummaguid, MA
Owner: Margaret Spatz.
Date of Inspection: _May 17, 2004
'FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): pd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 1999-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons-=How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy '
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system.owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 4130180-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM
x PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Country Club Drive
Cummaquid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_ ✓ (locate on site plan)
Depth below grade: 12"
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: 1000 gal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring 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.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom'of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of Y 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART..C
SYSTEM INFORMATION (continued)
Property Address: 105 Country Club Drive
Cummaauid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and clean. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Country Club Drive
Cummaguid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 ag l.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The leach pit had 3'of liquid on the bottom. The scum line was approximately 4'up from the bottom There did not appear to
be any signs of failure. A video camera was used to perform the inspection. The bottom to grade was ]]'.
CESSPOOLS: None (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: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Country Club Drive
Cummaquid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
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.
i
GAGA 6,(
A 6
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I
o It ao Ya
y O 3 a7 50
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10
t
Page 1.1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: - 105 Country Club Drive
Cummapuid, MA
Owner: Margaret Spatz
Date of Inspection: May 17, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high round r y g g Ovate elevation:
Using Barnstable topographic maps and water contours maps the maps were showing approximately 30'+I tozround water at
this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
c�
TQ WN OF BA STABLE
LOCATION �O C OU^1' G (b( SEWAGE#
VILLAGE 6,AMS A ASSESSOR'S MAP&PARCEL.JfS0 O°VO
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY / &W
LEACHING FACILITY:(type) T (size) /6"
NO.OF BEDROOMS 3
OWNER i)(S ro
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: ff�_
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 faci 'ty) Feet
FURNISHED BY (1 S , O/
i
Q ' rL
ao y� OF JL
a- as Y6 3
3 a--7 so
T WN OF BARNSTABLE `
LOCATION 0 1 'COU•, Cl CIA Pr SEWAGE #
N',JI.LAGE Are s�n ASSESSOR'S MAP & LOT 3 S6 0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) P,7— CX G (size) /6"
NO.OF BEDROOMS 3
BUILDER OR OWNER MArGArer E4eE2
PERMITDATE: COMPLIANCE DATE:
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 leac g facilityl— Feet
Furnished by wit tlX t. bn J Fo��
1
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L O CA T- 0 _Z�2 E AGE PE RVIT pO.
H'1 L L A G E _ ASSESSORS MAP NO' 3 5-0
PARCEL n'^ o qo
INSTA LLER'S Ill ICE b ADDRESS
v
. o UILDff R 0 0(30
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
, ;
J
No...........
......... Fxs............................
-_
THE COMMONWEALTH OF MASSACHUSETTS -
BOAR® OF HEALTH
----7o. .............or-� .. .% . / ....
Applir�ation for Diiivnii�al nrk.5 Tow5tratrttnn Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
- - _.... .......... .....-•-•- ---- --------------•-•
o --Loc 'on-Address 1- /.••''' - .- r Lot �/ �y�'
.......� e'/_ 4 c r�....... _ _ _ ��.....iiaJ �'�Y ... „^°'�-.�
,��ct
Owner ddres 2,r .
CE a �- �2. .... Y.... (..... �_�
---
Inst l k✓tler Address f__
Q Type of Building Size Lot_ ® .Sq. feet
U Dwelling—No. of Bedrooms...................................Expansion Attic ( ) Garbage Grinder 0/0,)
Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ...................................
d �®�oowi-------------------------------- -----------------•-•-------------------------•--••-----------
W Design Flow.......1Z..9.........................gallons per perseit per day. Total daily flow.............: "?- '._..•_...___gallo�s.
WSeptic Tank—Liquid capacityf/gallons Length._s9......... Width...,$;. ........ Diameter________________ Depth_._!"......__.
x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......1........... Diameter.._/d.o_S. Depth below inlet..j��. .2....... Total leaching area..?cF.`�!....sq. ft.
Other Distribution box ( Dosing tank
aPercolation Test Results Performed by..A'*J........4-0. .G .................................. Date.. !.._ .......__..
a Test Pit N0. 1'!5_ -___minutes per inch Depth of Test Pit__f.Jf.�__.. Depth to ground water.._�L.o,v.Cr.
Test Pit No. 2_.cZminutes per inch Depth of Test Pit---/yX..... Depth to ground water________y_____________
0 p � o- Z f= to s, --42,
Descri tion of Soil---------------••-----•---------.._... "� ......
�+ " /5�--"-_._..G•CG�9/V E�,�yr-s l'D C-�A°--" � '.J .f...
x �i-J- .Si L� .-1� - �J�`z.iy��-F�:- .............................caf�y�. '-----�-.a��.._.
U Nature of Repa>rs or Alterati ns—_ saver w en.apPli ble..
---------------------------------------------------_----------------------------------------•-------------•-••------------------------------------------•---------------------------------------•--.--•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
.. t1 '�
the provisions of f-i::T::. . 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beet/ issued by the boar f ealt ,.
Date
n�
Application Approved BY---- /•�------- --- ---d ��---..._-•---- -----•-•-----------
........
Date
Application Disapproved for the following reasons:_... ---•--•------------------------------------------ ---------------------------• -•----------------
..........................................................................................................._....__...........................----.....-----......._..---.....__..........._..._..........
Date
PermitNo......................................................... Issued--- .....................................
Date
...................
...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O s
p,.J A)
........I...........OF............... ...........................................
Appliration for Uhipoiial Works Tongtrurtion Permit
Application is hereby made for a Permit to Construct '01 or Repair an Individual Sewage Disposal
System
...............
. ............................................................... ........................ ........
Locpion-Address or
........ ............ .................................................. .... .........
Owner Address
Installe 7 Address
Type of Building Size Lot.Z�-----------------Sq#et
p
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage G
PL4 Other—Type of Building ............................ No. of persons...._____._................_ Showers Cafeteria
PL4
Other fixtures ............ ...... . . ..............................................................................................
I--------------- �1; a i 6;
Desigh Flow...... ..........................gallons per person-per day. Total daily flow.............q2...........................gallons.
1:4 Septic Tank—Liquid capacit 2s?ikallons Length__149........ Width...4,......... Diameter________________ Depth.... ........
,,Di posal Trench—No_ -------------_---- Width..............'...... Total Length.............._..... Total leaching area....................sq. ft.
Seepage Pit No...__��_--------- Diameter---- Depth below ....... Total leaching area.... ....sq. f t.
e
Z Other Distribution box Dosing tank,(
a ... Date..
Perc6lation Test Results Performed by..4U_:..... ............................ ----7------7......;................
i Test Pit No. I .......minutes per inch Depth of Test Pit../'
- .... Depth to ground water... .................
LT, Test Pit No. 2.."- ' 3—munutes per inch Depth of Test Pit__ ' ....... Depth to ground water._____.....r----------
...........7..... ............ .............. .........................................................
0
Description of Soil................................... ...............................................Z-�--------------------------------------------
............ ......... .........................
U ................................ ........ .............. ---------- .......... ...... --------------------
X---- ---------_---------------- I-------------------
Nat'u"_r'e'1ojf lepaii��teratiolis f- rfswer when appli6able..........................................................................................>.....
............................................... ..................................................................................r........................ ...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'211TI_- E of the State Sanitar Code—The undersigneTyurther agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board eal
S _d--- .. ................................. . . ........... ...... ..........................
V te
ApplicationApproved'.By.... .............A.............................................. ................. .............................
Date
Application Disal5provedjor the folloz_ving reasons:................................................................................................................
........................................... ...........................................................................................................................................................
Date
PermitNo.---- ----------................ issued.........................................................
Date
T
THE COM'M 0 NWEALTH,OF71M ASS AC H US ETTS
BOARD )F- HK L
......................0 F.................. ... .........................................._....
t,
IS TO B 7 Y, That the Individual Sewage Disposal System constructed or Repaired
.............
b . .... ................... ............ ......... .....
Installer-----
I— A - I %_ a444& JV X
a ..................................................... x.........&......4.. ....... ............ ............................................
installed in accordance ifli the provisions of" The State Sanitary Code,as described in the
has,,.been inst.
application for Disposal Works Construction P ... ....................._ dated__/:'� end. ........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATI..........L..................................................................... Inspector.........................................*..........................................
Z .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OiV AK
HEAL
........OF..... ... - ;! .�..........................
No......................... FEE.........1�......--------
permit
P ermisst,'o • hereby .............................. .....................................................................
, y,,kg' y granted----. ..
S..R� ystem Z7
gr A.9
to Coas air an InAl
........................... ...............
at No................................................. ... t� ......
S t
-- - ------------* - k_X_d.
).../)Dated..........................................
as shown on the application for DisposalWbrks Construction P igte N�0.461...... ... ............................I................................4.�7�/ ..
DA Board of Health
TE.....�/ :.r..........................
FORM 1255 HOBBS & WARREN INC., PUBLISHERS
tos-
L0CAT 0 E AGE PERMIT qO.
�Z e
VILLAGE ASSESSORS MAP N TQ
oqo
PARCEL
INSTA LLER'S N ME b ADDRESS
BUR E R 0 wq.ER.
DATE PERMIT IS'SIIED s
' DATE CO PLIANCE ISSUED
r
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