Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0053 CRANBERRY LANE - Health
7 n r � w' A d d 9 O 'u ,:ir-.Y.-fS,. :. ., ... _ ., �,-,.. �t ;... .�x�r .x � �19,i:4.w.r n •�.,�'a`° a.': i"3''%Xc. r t'tF „.,.. T r ..,_. ,,.;.: < t„,,. 1_ r _fir' �� >.,•'e�ia„-� ..'Y:,-.:, s. .+'..,-H...",. .: ,. ;a r.',,: .. ,a.A.. +C,_ �.,, , .. a. t.„ :.... ,,,. .•ry , ...a�. ,:J•�rs %� ,.^4+,r:.ih,. �:.. ,. + .„ a^�s:.-. ,;y> r.:. ,v. e:, .fi. s s-.-.�� ' �... x �"�d? ,�}',t 1..,,J g� ..,H,. .a✓,a>., .3. ;:�.• a. ) '..<,.•. .�yxuxM�t ;.ar:>;. '�.c. r�` -x:.�%' ,gC}� .;.. ..:.Y .-'r °^ 'v '" - y,� ,: � .::. ,.. :-„ `� :.�z' :: ,,.,.zrd•� ,, 4i • Y �+ ;L'^ ������'*Y• p+�.}"° C'�a1 ,da } ,va -; .,r, '-. + ;r - ,.. r's, f�ts:x5. at. rw i:^' ...N � .... ,`.�:.•&�'� ,,:� � tE F% :`�'�3,� 'il-a i -a .T,# a.. a 3� m i :u ':.rv... ,� .. .:. ... �, tII :ro 5-':r�x. .:-j3yy .a...v:4b ,!l 4 » , 1::'.. r-..., S ...., 8.,. '�,':,...:. ��al" �: .''hL :.t�.x, •,,!'•5. :a(" R :.,9f r j,: x�,. ,.Sr„ww.)e; "� ',. .:. ..< a '.a .. ,',' a.`9!'}T.'1-. >. .. ,A,. .<, •m «. r- .,a. `.a..,„:. . . ?`.' 'al`•.:'", ,. ,.. :4 y.3 ,. , i. s .,.,a e :., a1:�„':., yy.',. '..:r : , ""Au'} ,. H". .,:,. , :, ,: Y.'.,.,.: :"1 ,f'iNi6 -t:. C.M2, ,�v ,�,✓ ...,. ... „y Y $. P v a. ,:...:- ..,., s«. W'.'•4 -. ..e.. ,d 'VA. ..?{ , 'F,y Wit•. -°9,.x,. i,,: .F"''au"' 'F qyy F '�• ,:ff_,,. ,• ..- ,:a .e.. , 3 d?. F A .,y ] .t' d"� qq1• ,v+ ,:. .,��aG ..!. .. 'az,£•a c'i•...., ..;C!, SY��,,yy.. :'�, 5 r "U •�"`,'.':YR.�,q P". ww..dx c s ,.wr.. sx. M. :t%.. ....• „ .,Y`v'..,,.. .._a -". A.. k•. - ..a,.b� -�. , :,.1. „., :r qt ,:.. �, r .., �` :,1:mt' ., x ., s._ ,. .,.8%�� �'. , 4;;.., �.�1.:..". ¢; -..,., a .v)' +:�.n... T :. :..i, ,. a. .fi', ,.. ,���..}}x?: ,.. ,. ✓, ,. ..(r- ., ...a „ ,"I..... i;.MP a <,.. .,.. aS. ,n...•fi ,p'� S.x. �'f ... -w .-. � ,..:.- ...., ,,.,... ➢." 'A.;,4 'C . :��.ar aaSC,'`.. .:,-,. _ ,y}�,.r„7:. y, ! Mv�VfS: .,'�" . , , .,04. yE €::x. '�g�. uc,tJ.,,, -: . � r .�'. !«':" �...a , ,� , ,,... :,*:: ;.e• •..,,. � .� '.' „= ,,......, .,,, ,. , w: - ,,.w "b k h. , d ,, "„ ,5 s. a. �.> ,4 ..Y,. : , .4..... :., M -, 4, Y.,,., 'if - : a:. �.r`'#�., k,.. 5±. �. L r.,. � 'iNp* "�'.. ��ww. ,.. ... .•...^i , , x6«.,,.=a'• d? c. 3Va.,. F,,. x,: ..Aso-,. e.3.. _..... r .,, ,,.: ... . ,... , ..my[-�,'-$x.,<.. w. ...». ':, :'e•..: ,i.,R'4"..A., . ., .: ..*,;.. �y ..'`. , ....,a•. .. .,. ..,,... -t...` a .. .. =. `�,.. �,. � ,.,.. _. yy 'Y3.., .. _ #, „7 DD �-'.•,�r� ^'. a,a r�: �: ,+,.•,,,, Y6 } a ., ,. .....,..� St.. , '. .Y� -. '•',:. .: ,. :.,.:�. �, ::!!k„'. :r.5a r 3;.. $qa•,�m•. ,a. .a. �_. _•,' a.:,, ...: ..- ., s �,^ w v-. r. .. ,: x , ,. �,.y ,,_,•.,.....•« .. ,.. ."tm,.a., 'x h, ,aa,. l- .: :..' ,.:,5u. �� �`F.. -. } `r•,.... .....:,-.4.r. ,k., ....e ,,. r.a�„' M. V 'n"�..� '�. �. R. x$ T✓-.k' pn r�� ^ y�, .... , .. xr". ..°S ,v tom.,, *4•#i e*"re. -.,,4;r ,... kq.. ,.S„a.b�; a '.,+41`.1 ... _ 'A. , a4�`ur af":.,..o•.. '.., ,... [ i�..$-. ,.�.�t ,��m5�..'n•T`: f. dC,...-.k '!BCy:�.,.�P,y ..:p§" ,;w a ,,ay��, MCI � §." s ..,,,¢¢�a',� ,:�..,. -. •.t�`.'r .. ;. 4t:n,.« '€r.. ;. ,.,:�Ci. .....xyy� .,<':.:,.. th,i .lL:.,a M� y �,:...� ... a.- `:�a. �. .. ....a r,- ,. n :.xS .�p.�..7' �h'j��:... :Y fi N ';... .. - _. C a...: .: .. �. a d, ...-, «.�g� . v•m) '�'9..-, ... f- 't:. �. .... ... ... .. ,� .. ^,r 'a.Y ,_ , � x ..,.,4 >,:. „.. , x f+r; x... ,. .: �_ .'�, ._ ,•.+'-� .- ra:^,rid 'm,>s , :`'�..> • a. ,� .a<.r,:, .<,r, �_ .,- s. �..r §_.� ., ,„. n „�d , ''�- . �: ,�x. :�.. � .,+�i: a� r ., ",.� ,. d: a .:t,_ ,.. k'.} : ..tea ...,x,"_. .-s,.,��' ,. �a ,a:.,S, a .. .^ .,,r.••Cd'�:, ;;t.. �ti.:.,. .4.;t»..�:. �,.... 'a 'i� J:. ,:e..... . >43' ... �., t.... .., ,-w: .... ,: .._.h. " ;1:: .:� h:..,y.•. ,.den .w„ x:,,,., art. R..� f'N i „ >n,..,. ..4.....cz t�,.,.'�!', , ..> '�•#, t#.. .a, r Via:.. :: fit,4.:,,. .�'Yfi.,-.. ,... H..i _. ,k�.. .,, ! . ,. ,,, b :.} ,. >•„.fi,.. k,d .:.. .. .-w.. 4_Y.A++. ,,.. .. , f, „•_., r. a ,„... :.,. ','3 .' �i't.. . , .. J, :..r<.:. i ..,e.t�-. ),: •^+ .a.�-tl . ,: ,.yy� . -.. .h 44. st. ... . , .e ,x.,J" ,.,.. ' �: x YF•u ..2,... ,.�- � ..._h,a... .vS. { .. ,.x-.. i �^.: ._ •,. r:.3, ..� l ,,a.�. .,.. ,. ..,t<.,�..^: ,. :,4,.. ,h:t. :, s� .: , '�' ..: .n N w �� �. x. , .. �� ,, a a F•'. .$ %i- .Yx a..,•! :i<,: ,.1.ha ..L-i,-.,:.H M ,. 'A...(. 2n.. .- - >. v a n ...:,........ » -,� ��''� 6 .,.. .. •;St'N. `A:" 'rr,9y :�v'? �'� ,,.: .' _,„.. :,.. _. ��qY, ,r hf!�,. SK: ::3eq; o,., w_ ,..'a�lf�v .: n :,:. �P"r7•a,. � ('� :..- .. .,:. .S `."'%n... ;^" r, .r. *F d � �F -' k ._-�d :. �:3. .. ," �` k .a•:. .., ..:1 ..,�k:� 'x Ya.. w,'r f` .�'• a^ro• , ,13x •„ oa4'a:',., ,a;«+.r,v ,sm,,.: :+^, a -•. '.. ,.; ,k �r A ,. '�: ,y,•m�,'.��, ,..u,:. •w.,.:. ,.. G� ,r+!> 4«,p�',s�a ,Ta, f';: ,�`�.. .fix " r q„k'b� ,. ,�'.x,.. _ r,.: ', y ,xrt ,.. • i iy ti`• •'.. .. x...�, :{:. "" $' � •F 'fx a "a «;. aV ^Y ., .F , ,., ., ., .A i 6 ak s ei ',•y?? �9�. .Irl,.-.�' .r`Q .t� ,M:..n.; t t�:t t�a :.a b t„ „ •::..» rva, ,,, ,.§. e $$r�, -y,: • '.Y A SaY rl, <-�:.r ,. ;;':,. ;,:r,. ` .,1d,9, • :, _: .. ➢ ,.. „«��' �. „>4.,>a... _ - ,?a �' `k 5;.: s?.,N k.`p "r• t,:,G, , r. r, z _ ..' .,, , ,,.. i.a :#,.. r.,, 4:, k « -, • 'r3, .. �s. .. -t"S ,, 't�.#r. N/,•..k t§ ��33__ „rk,..�ii•. h 4�.e.. , �t ,.. .h}T fR' , :. .✓ ,,y�a .:'. f�. , ,. T -�. ,- vt �:,.:d t k,��'.' � ,�j ray W-: h .,, .,. .1,.. d+ z�ei, '�t .. �q,... ,,.hs-: -,-r. :Xti t ,T��`.. �}.� ., .p' a Y°� ,r r,• s'..._ ,.,. eta E.�}e,. .,4:'�'" Spy �.[, '��, -„ ea .-. .,y .� ,'€ :.... fir' ,,._ �. ,:.., s, ,: .._. ��` �. ,.. *4 �'�., =A�`..P� :.« ;.. ..t *,�� ,'�>.�"'�, b�• °+,� n,.. .- r: �-....,.. »..... a..• ,.:., ,. a4 r.- a., i.. ,�`,�„��y',` .�;. 'k0. ,._.n .- ♦ t' 4 'ai, •a : Y,,•,ark:f.. 'R.{' y� .� ,., :a:'8 . % .. .. ....�e �':'ra?,,..�p.f „ .. , ..YF •d; .,, q ..'. :,�W"e i. :.._I a�S •4.. X N r ri r rvry .r w A, a i , f •Y' f i• 1 ',�, cl ?r4S'P � 't mY„a` �� �i'" Yt S S• � 1 ? 5 � Y w, , e _a 't.. J h'fi kr: Y � f'. °r1 pr �'fi w`.Nar�'•� .i+ai •{. .'�'',1� ,Y r e. 1 p C M ,. '� ,,.,F' • u.. ,:. -` , - _. a�. a�,Ar,-.64 ,3`'s� �-� , hP' y" e •d�: ,cr �' ar' � t -;; a .:,w, ::.•. -�:m : .. �.' •. : a S a �� ��_�4>•,:,�`. ,:.•c+± yf� ,R�` '°R°r. ,x�. ,: , , ',. _ I � '3. l7'T! �.,Y '{ i y ir*o ab t � � ` F u i _ `. ,,l - •a'..- � ,,a1. ,',, .� .. ,' .,,.:,, fdWd irk , ,,! � ,� k r�� ,I, l -. ':� °'�. .- :. .., !-._..,y, :i "w ,�.': ' :ar��. :i-' r. ;�,. t.i°' �'w � .�,' �Jk� �$•,g� '� rf�t�,,4�� �• .� �.M � tf�,}:, ,, •,.QaJw- `YY Y,', ke � .*rr "4§'" �, 'w'. t. '�-:"• 4 � w ,$ .. „„ '!s. Y.: "..: r, 'S'- "k,. t;� `F'3�• ,j,. A ;`:a .. ..e:• „ a::^ .- - 2�&7'.- ', ,;;: .. - >•, [r a,,y �v nd `'asx l.. ,) •:�: '.�, c, :e, � m.: , ��Y�i :8, ,-I�e, a - .tub`,. t -.1 .�r�a"e'"�P + pr ro r r, �I n ) III I'll, ,» , ,:' .. _: `f,N {.. .. .. •a '�'. ''., -,.. .''99 Fr• c,,, w .,.: s ,..: ".,.„ "i8�?� �, ,,..Ax t a.r� �,% " nY N�•�i, r ,. ,x. ..,. . a er':. •. .. ..X:` a�. �'Sf$4.. _.,;: m .. 3, ,., , , ,,. '.,, ' ;.r... "4f:' -,x„". , ,t. ,r�i .t:: ,. :1 x. .. r,e_ .. , 9 `�..... ..v d;. x :� sY:o-".:,•. .t,n: � ., .. . '�' s e ::a�; ,,Y ��q,, . M e- "...,. ,'. ,fT :,. : ,r ..>. _ ., :.. -v.. a. ,. 4 ,.•k .., : ark, � �. .:t n •. .. ,: ....'P. r -'�.,,. �+4; ., i. .r.a ,, .,. s ?e.. '�• � la a. ...,-,.r-h� .4.,.,„„55 �:", :.,z .. �t,�..a i �,.: ,• e.^V.?r-" .' .,. ..:..,. „ .... ,. rA t g3�..... � n....h,s.. - , d :.M .... .::7. �;u�'' �.v ,✓ L� � W�:. I t _ ':: .. a:.� 4 !s:, .. ,.. r .r..�g..,�., . .4,. � '-m.-. , ,, .- Xr n,; ,. a+x, 'r U.34.k Y• .'d,. i ,..k.. ,"'. ,. .,_.,. ... .,�,: ..a ,.P: ,, ,: : -1 x v, .. „>. a.. `��' ..@ _..w• "n :�, r t ,n- :d,_.-t -•fir+ A_ `"4 �,k>:'F �. -.,L',.. ,, , .,. #.. o; -: ,'x•<..,. «}�:. .a. ffi. ,.«..� ....{- .... fl ,..,a. ,,, ., 'Aa,,a., ,M1.&._.... ,za: 6`kC ,:fir,. rN' �s.•�4.:f " „ �, ,; ...a ,.i"x-,..4 :. . „ . ,. . .. - ..:. ... . „.., «" .: a ::. ^ae rr, .., .._ P. ,., ,....„^ „�.., �N k,... 6i7a ._aM�•r ar ,.. t�'S: 1.. ,. ,,k .. a ,� d , r`•w�" .. a,. > .,.e.,..:+e .. � :..a... -_ :��.'. ur. a .. 1._ ,. :.�.. �. .a $., ,. .:r• '..._a , ,: a ... a :. :.:�_,a� .,�4m.... .+. ,--. -. .� .sd¢ ak r. ,,d, '.., �... ... z.. .r. ...; ,... ., „ .. ..a, .x..s��vi,,;'�' ,. , •�,: -k «. ,- ,F ,.:.:£ .w, :,,i;.4 `xr. a._,.. :r.„. r, .. :.f '�. s, ..rr,cz:..:C,. ta.:.• :_ .. a :. a .. 'Lj•,e 4 ,e. , , ,a...-,� +ri ... r,. •t": ,, uk,a 4:. ,av-. ,v P.1aF1.'a',ve M... �XI"AI.'. ",:. : ., .. ..... .� a.: .: y}Y� .. en, fi... ...,,... � L .,. Ep.X....,Y.. .. ,. ,.. .,,.k .. -r;:e:• C .l, „ e,r'T r„�Y, ..�, f':Pr, I...a Y. {` +1:' .. nE"' a: � ..t ,... t,3" .... ,.,e....S .. , ,..,.,..k, «. v ., ..r•; ,i f ..a d:r - r.. 'Y ti�^f. 5r' W" -4'S::•.�,, ., `6: ..k. >w.. .. r ,r .. ... .., r f " ,,:'a x: ?:.. ,",.: ,^v �••,rakc.4;a „_, >.,ti,,,,.�, ::a._.v.. "'S, ,�!, +.#4. x > ..�. ><•, d. ,t., s n , ..,�,,, r ,�e�w'���'•eR ,.: �x;ao�. _. .. .,:,. h g5..x 'R .. r.: , ,... ' :. �r ..'dd5 ,-uZ' ...� �^ < :. :. ,a✓ ,, aws.. ,. .. :d.. -z - ..,.. - - �. ,�;` 4x. ., , ...,: ., �., ,!Y ;:t.P 3',(k �. ,.4"4�rr,,a, � J'"z.a>".S„ A� k:H+ t, ,w� :.a 5 t ,. .,. ,.,. ,. a,,...r _x :„ 4 ,. •..r .. a.. .,.x . .. r-t # ,,.. ,. .: , ... ... ,..... W,m+,f� ,dm a iYe k,`,�t1,t. £, 1 1)�. J Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection ? �EC¢ E ' One Winter Street, Boston MA 02108 (61 n 292-5 00 2000 7000FSARN r HFAlINOF TRUDY CORE 'Secretwy ARGEO PAUL CELLUCCI $ I)AVID B.STRUHS Governor '""""'' Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 61 Cranberry Lane, Centerville, AM Name of Owner: Kristin Ryan Date of Inspection: May 1, 2000 Address of Owner Same Name of Inspector:(Please Print) James M.Ford ' I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osteryille MA 02655-0049 Map: 234 Telephone Number: (508)8+62-9400 Parcel: 25 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Eval on By the Local Approving Authority Inspector's Signature: ' Date: May 2, 2000 The System Inspector shall s a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS, revised 9/2/98 PneIof11 - Primed on Recycled raper _ ' , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Cranberry Late, Centerville,MA Owner: Kristin Ryas Date of Inspection: May 1, 2000 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 61 Cranberry Imne, Centerville,MA Owner: Kristin Ryan ` Date of Inspection: May 1, 2000 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 the public health,safety and the environment. 1) SYSTEM WELL 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (appro3dmation not valid). 3) OTHER revised 9/2/98 Page 3of11 ' f SUBSURFAC E SEWAGE DISPOSAL SYST EM INSPECTION FOR M PART A CERTIFICATION (continued) Property Address: 61 Cranberry Lmre, Centerville,MA Owmer: Kristin Ryan Date of Inspectkm: May 1, 2000 D. SYSTEM FAILS: You must indicine either"Yes" or"No"as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded 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 1h 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for eoliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pap 4of 11 f .. SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ` Property Address: 61 Cranberry Lane; Centerville, MA Owner: Kristin Ryan Date of Inspection: May 1, 2000 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:. Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. r ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15-302(3)(b)l• _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. 71 revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 61 Cranberry Lurie, Centerville, MA Owner: Kristin Ryan Date of Inspection: May 1, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: n/a g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry(separate system)(yes or no):No; If yes,separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1999-58,000 gals.:1998-54,000 gals. Sump Pump(yes or no): No Last date of occupancy: C}rrrMOV occupied. COMMERCIALANDUSTRIAL: Type of establishment: Design flow: _ gpd(Based on 15.203) Basis of design flow Grease trap present: (yes or no) — Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pw►wed in 1992-per owner. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9./2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Cranberry Lane, Centerville, MA Owner: Kristin Ryas s Date of Inspection: May 1, 2000 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Continents: (condition of joints, venting,evidence of leakage,etc.) SEPTIC TANK: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: t Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) 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: a . . Date of last pumping: Comments: (recommendation for pumping;condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Cranberry Lm►e, Centerville, AM Owner: Kristin Ryan Date of Inspection: May 1, 2000 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) 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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Cranberry Lane, Centerville, MA Owner: Kristin Ryan Date of Inspection: May 1, 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,if possible;excavation not required, location may be approximated by non-intrusive methods) If not located,explain: , Type leaching pits,number: 1-6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system Name of Technology: •f. Comments. (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The pit had 6"of water on the bottom. The scum line was at the same level There were no signs of failure The bottom to grade was 11' CESSPOOLS: ✓ (locate on site plan) Number and configuration: 2 with 1 overflow Depth-top of liquid to inlet invert: Depth of solids layer: Both S" Depth of scum layer: #1-1"and#2-0" Dimensions of cesspool: #1-S'W x 6'Tx 9'overall:#2-S'W x 6'Tx 11 overall Materials of construction: Block Indication of groundwater: None inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) The haudd level in both cesspools wws up to the outld pipe. 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Cranberry Lane, Centerville, MA Owner: Kristin Ryan Date of Inspection: May 1, 2000 Map: 234 Parcel: 25 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3A� �Q � -oec.1C i 3a- (od M3 S-7 , Of revised 9/2/98 Page 10ofII SU BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 61 Cranberry Lane, Centerville, AM Owner: Kristin Ryan Date of Inspection: May 1, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 30+1- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data v Describe how you established the High Groundwater Elevation. Must be completed) The bottom of the pit to grade was 11'. Using the Barnstable topographic map and water contours map, the maps were showing approximately 30'41-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(Al W 247, Zone C, 3100)was 6.5'. 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 property 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. revised 9/2/98 PneItof11 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE� ASSESSOR'S MAP& LOT-L4 =' =. INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY N I LEACHING FACILITY: (type) i (size) 100 CS qtir,,.� NO.OF BEDROOMS BUILDER OR OWNER �eA'PrN PE LNU=ATE: 1 i\ COMPLIANCE DATE: Separation Distance Between the:. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 2� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N 1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300.feet of leaching facility) ly Feet Furnished by 661. • , A " C0",1'%10\«7F-ALTI3 OF M.45S?►CHL'SETfS '�'�N �' �;F. °• '�--''�• q� E"ECL7J' E 0FFiCE OF E.NN1RO�N1F_\ AL:A tFFAIRS, . _ •- . r - 1 v ID 1 �R' �i ' 'F A1':.OF EN-VIRONNIENT PROTE•CTIO`i ' 0 E WINTER STREET. BOST10%. A11► tl_It�S�Eli1 44'4co t- o` V4ILI.IAM F.V►Iit1 '� t TRL D) CU : A , t [e az ti9y ti�f•'Ctrlt«' �. s�� t Lai, s 9 '.' O� AAt3i;OPAt,'6CELLCCCI 3`9�9� D. 7t)B 51Rt: ➢.t Governor 3" SC1R 'URFAC€ SEWAGE DISPQSAUSYSTEMINSPEtTION FORM [omcrissio €� i� t14 PART A UT '®e 4t" t CERTIFIC#►TICih 4�� 't :W r� ek (Q Property Address; l k Address of Gwnen`",= o�lth.+ Date of Inspection 1 � t « entl !, a. -9•t1 Ii . f drfier ': �>t' _ Name of Inspector. 1 . 1 am a GI P�ap�raved system inspectoripursuant to Sei tidh'115.340 of Titla a (310 CMR 13.000) Company Name:A_.S 4,a - -: Mailing Address: Telephone Number: fT t tf CERTIFICAT10% STAjjME%T r w y. r< 4. '• y $*�: �.8 ` t ee^.eft 4ha. 0 have pe•sanalla tr+sReced the sewage tsmosa' s�ste^ a tht5 add►e-s and that,the intnrmation reaortea belaN is true. accurst s n mv,;ttatnin and ex •fence`Iri the rs •fLreier. and and caf�alete a: o`the tune of inspect Tne.Insp=.on wa pe arneri ba. © 6 g R� fi r *" e rna!rtte1ance ®•on-site sewage dtsposa `%'stems'-Tn@ KKieT v • ' 4T r •' Pale` x ., Corfc!t,Qnai«� Passe '.f 14 Y %eac Further Ea'atud2�0*-t:t't�e ®fit Appraar ng At$nd to Inspector's Signature . R Date': ':;,e S•`S,eP tr,5t+eo®• shall sibma4,a ccpv at this ins®?:�pn reaCr,to tfie ApQra�tng AutfiCriri< wtthtn-ththy 130! davi 01 carttpleung this inspector., lr the system Is 2 shares ''Sterna ha= 2 Ge_�g'+ floe Q:10,000 goc dr greater the IRst?e^+Cr anGt,tf'e SYs.e•r {Owne°ihoti subrrf .the reponic the aaarorriate tea,erat.orici of thexDe;a.-mer<t a Envfrenme W Proter"tar• Tne Qrig!na,should be set['tC thessystesn Ova! and copies :"-I:to the buve if ar piitablta. and 1ne approving'authOrin , `f g R INSPECT10% SUMMARY: � r Check A,�}�.zh �, or �`r � � �.� ' �� ��� �� � $ax �e A; SYSTE.'+� PA55ES ;<� � �� r F have not fouefd'any enforr.;ationtnrhlch,indicates that the System vteiates an}of the faitl,re criteria--as'Benner: iti 310 C!vtR 1s.3( Any laAure t tter:a nat'e�?aivatL are rndtct� 6no�a. _�• COMME!�TS: Bj SYSTfjA CONDITIONALLY PASSESgs� ®ne Qr-more systems components as des�r►i ir►the" Pass"gectttln deed tc be replac!ad gr pain The 5sster�t;u .Cate pietigri of the replic6mdnt oe,re�air,as approve the Board Of Heaith,*_1 pass '' ems° N- Y f deeermination to ef) Instances- tf'not determine:';;explain why not r .Ind!s:ate yes nC.¬ determined (Y. h, 6r ND! a Nscribe basis o . The`s�pt►K tank:tis meta, unless the owns►or ope ator has ii , id'the system inspector with'a c©py,of a Ceatficate ow . Complianceslatta6hedi Indicating that the tank`was installed within twenty(2t]I.years prior to the date of theyrmspection . the.septiC tank, whether or not distal, is c�raaed;'structuralt unsound,^shows substantial'infiltraiion erexfiluatlon;'or is Imminent. The System will pass inspection if the a isisng`septic tank rs.teplaced with caritarming septic tarp a` approved by the�$card of't'tealth" x. t pV< ,'n,.g t SUBSQRFACE SE)h'AGE DISPOSAL SYSTEM INSPECTION_FOR.%4 . . PART A - ." CERTIFICATION (continued) ;,t _ Property Add�ss: - ,z Owner: _- . _. _ • _ .•N44 A�,-P' � -�:. Date of Inspection: ,.�.A 61 SYSTEM CONDITIONALLY PASSES (contin-i d r a Sev►age backup or breakout or high static water level observed in the distribution box is due to broken or obstructed _ pipets) or due to to broken, settled or uneven distribution bo), The system will pass inspection if(with approval of tt!e Board of Healthi. Describe observations: `Y _ broken p►pefs)are replaced : '' w obstruction is removed 'distribution box is levelled or replaced ®' The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass Inspection if(with approval of the Board of Health): broken.pipet-si are replaced- r r obstruction Is removed . e • ray: _•`—� _ _ —. � _ . Cl FVRTHER kti'ALUATIOV IS REQUIRED BY THE BOARD OF HEALTK: Conditions exist which require funhe•evaluation by the Board ofHealth in order to determine if the sy-stern ii failing to protect the public health, safer'and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF`HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING (h ,4_M' AN iER_ WHICH WILL PROTECT THE PL'BUC'HEALTH AND SAFETY AND THE ENVIRONMENT; Cesspool or p►v� is with-in S0 feet of a surface water Ce-5poo! or pntiN is %ithin 50 feet of a bordering vegetated wetland or a salt marsh. r 2! SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) EIETER.MMS THA' THE SYSTEM 15 FUNCTIOtiitiG IN—A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONME4T: - The sv:,ern has a septic tank�and soil absorption system(Sets,and the SAS is within 100 fee:to a surface water su. ly P tributary to a surface water supply. _ Tne systeni has a septic tan!.and soil absorption system and the SAS is within a Zone 1 of a public water sup iv well. The system has a septic-tank and soil absorption.system and the SAS is within 50 feet of a private water supply well. ._ Theste•n has a e tic tank and soil absorption system and the SAS 6 less thar. 100 fee,but 50 fee!or more from a s a septic rp private water supply well,unless a we!I water analysis for coliform bacter►a and volatile organic compounds indicates th, the we!I is free from.pollution from that facility and the ,presence of ammonia nitrogen and nitrate nitrogen is equal to a less than S point`Method,uied to determine distance ` (approximation not valid). • t _ , 3) _ OTHER Z. fteviSed 04:28/311 ''Tt, a 2..'04 10..;•, ,� SUBSURFACE SEWAGE,DISPOSAL 51'STEM)NSPECT10% FORM PART A CERTIFICATION (continued) roperty Address: ,wrier: r ate of Inspection: J SYSTEM FAILS: ou must indicate either "Yes`-or 'tio' as to each of the following r e s I have determined that the system violates one or more of the following failure crite•ia'a<`defined.in'310 CMR 13.303.. The oasts for this.determination is identified below_ The Board of Health should be contacted to determine what will be necessary to Correa the failure. 'es No Backup of sewage into facility or system component due to an overloaded or'cloggeId SAS or cesspo,ol; " Discharge or pondtng of effluent to the surface of the ground or,surface waters due to an ove►loaded;or dogged SAS or cesspool .. Sta:tc !tautd level In the dtstribdtton box above outlet invert due to an overloaded or clogged S45 or cesspoo' Mould death In, cesspool is less than 5"below invert or available volu►ne is less than 1/2 day r10: :I t Required purnp,ng more than 4 tomes in the last year NOT due`to clogged at obstructed pipes. *umoer o times pumped'.. Anv po*.:on of the Sort Absoratio�•Svoem.cesspool or pr►rj•is+below the high groundwater eie.atior.ry Am po-on o-a cesspool or pr►yy ►s within 100 feet of a'surrace water suppl or`tributan to a surface"v+aie-supple Ant ponion of a cesspool or privy is i%i her a Zone I of,a public well. Am pc-no- o;a cesspoo! or privy Is v6thin 50 feet of a private water supply well An% por:.or o-a cesspool or prtvr Is less than.100 feet but greater than So feet from a.priyate water,sut:ol well with no acceptabie Ovate, qualm analvsis.' it the well has been analyzed'to be acceptable. anach'im, o,.well water analysts for coltiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.' ;. LARGE SYSTEM FAILS: , au must tndicaie eime, "Yes or"tio"as to each`of the follow►n ct' The roiioN:rg.c•Ite•..a"aea. to largo•.stems.►n adottton to the criteria•above: - The system;serves a lac}lin,v►ich a.design flow of IO,ODO gpd or greater(Large System;and the system is a sig7iftcant threat to public hea!th and safer, and the environment because one or more of the following conditions exist: u- rs 4. es No t .,a ,a. k , a. the system is within 400 feet of a suPf ace`drinking water supply the system is within 200 feet of a Iributary to a surface'dritiking water supply the system is located in a nttro$en sensitive area(interim Wellhead Protection Area-IWPA) or a tripped Zone II of a public'waterasupply well) `' ,.• C c. q _ e - k.• he owner or operator of any such system shall'bring the system►and facility into full compliance with the groundwater treatment program ,qutrements of 314 Ct.1R 3.00 and 6.00. PI Asii consult the local regional office iaf:the Department for further iniormatlon. r.vIsed a.;zsis>> ya.Q. 3 of 10 v r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM * , PART 6 CHECKLIST s' r Propert-. Addeess: Owner: p•� Date of Ins eLtian: k Check if the following have been done:,You must indicate either"Yes"or"No'as to each of the following: Yes No , P pt rig information se f rmation as provided by the ownei,occupant, or Board of Health; a{ h um have been um for at least'two weeks and the.system has been receiving normal h vstem componentsP P� None of the s. nth i —n flow rates during that period. large volumes of water.have not been introduced into the system rese o as part of this inspection ` As bull: plans have been ob amed'and e-ami• ed tgote.�f they are not available witK MIA. _ The iacihN o►d%•elhng .+;as on spa Red for signs o�sewage back-up. ' 1, ,. ' I t• � F.. , The system does'not receive non-sanitary or industrial waste flow. � f The site was inspectel tar signs of breakout - Ail Ester co^+vonerns. excluding the So-i Aosorpttan System,have been located an the site. `^- _ The septic tank mantiaies Kere uncovered. opened. and the interior of the septic tank was, inspected for condition of bafiies or tees. materia' o'construction',dimensions.deptn of liquid,depth of sludge,depth of scum, < The size and location of the Soil Absorption Svsiem on the site has been determined based on : �.. The fac,l,t� os+ne- Ono occupants. if diiteren: horn owner,'were provided with iniormation on the proper maintenance of Sub-Suriace Disposal Svstem. Existing'iniopm- ation: Ex Plan at 8.0 H w, Deiery+{ned in the field •i•an% of the failure'Cnierta related to Pan C is at issue;approximation of distance is, unacceotsti{e [t 302:3i:b't ` ✓ n .. .`�• �, y.. .. a .*} � i 3( t. .- • • e •y r • Y ICI ' I (rwxsod 04/25/911 Yagp 4 at 10 Ad SUB SURFACE'SEWAGE DISPOSAL SYSTEM 1%SPECT10% FeR--t,k` s PART;C ', Y µ w SYSTEM IhlFORMATIO'e,'i R ¢. Proper!\ Address: #�, a h u � Owner: { Date of Ihss ection: f s r� TF a` Y FLOW CONDITION � � 4 's RESIDENTIAL: - 'r t� � Fx • z. 71 y�. Y Design fiotw330 p.d.nbedroarn for S q.5 Humber of tearooms,40 Number o�current residents 40, � Garbage g•,,der(yes or nog 41 ¢` Laundry co!^ected to system(yes or no':, u Seasonal use ayes,or no,. Water meter readings., aa!able (last two iZ ea s if v- .v r ua .sage ,r_ i Sump Pump (ves or nor do .i ' � i'� �� k... � '�' Y is .� •A �S I L Id -4.� �': k , �Y •� f�� 5 �` .r LaS_date oa occupant:\ COMMERCi4L`I!yD1lSTR(A�: Y,� ' s a'` s: ., , s u Type of establishment t. v ' Design flo%% !ion Aga vda\ Crease trap present n twes or no u w * a 4 r. t s industrial %%ante HoldingTankpresent. g ` r„ N ';on-sanitan waste d,scnargec to the Tttie s c\SM1e►n_'{\e5 or no 1�wer meter readings if ava+labie: Las:pate a;o -..;?.Icti OTHER: Describe last'cate ci oceucalc } q s � .�` GEtiERAI INFORMATIO% PUMPI%G RECORDS and source faf{nnforrrtattor.i System Dumpeo as par, otp inspectton.`i�—no If yes. va.vme pumped - Ralipns Reason for pumptn t r „ — —� TYPE OF SYSTEM z ' Septic tanluWistrt ution boxy"sots 3absor_pti system �' `* `r ,! Single cesspoo) � i3 t�RC1 f s Overflow cesspool, " #} .• x 4 3s. ° x : Privy Shared,system(yes or no) Gf yes,}artach pre`vtous inspection) records, tf VA Technologv etc.•Copy of.up to date.contract? Other , ;APPROXIA4ATE AGE-of aft components date installed (if kriowni and source tnformatton:� Cj�IV[ Y '�;wt is �aA ,f • ;E L�y„r.. -� �°�.w- _,_-,e �, t.:.$ �tia,.ax, z +r:,4p _ ', .., + � �1• wi y * { ' a ` Sewage odors detecfed when arriving at theitte. (yes or as � r 8 �. (revised 04/25/8'1) �y Paar 5 at�10 w .b f — SLBS.URFACE -S AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 14ORMAT10% (continued) Propertv Add►eas: + e: Owner: h , .k r ,t Date of Inspection: , BUILDING SEINER: (locate on site plant w Depth below grade. . Material of construction. Cast iron 40 PVC_other (explain` Dtstance from pnvate water supply well or suction 1i- , Diameter Corttments: (condition of joints,venting, evidence of leakage. etc.) SEPTIC TANK:_ (locate on site plan `_ t Depth below grade- material of construction: lconcre:e _me:a _Floerg!ass �Pol ethvlene _pthene plain, If tan: �s metal. Is:aee Is age coriumec o� Ce^'ticate oZrb Compliances�o D imensrons Sludge depth'D,slance from top or s!udge to boro-+ p,Oune:'teeScum thickness ; , Distance from top 0'scum to top 0' Outlet tee or baDistance atom bottom 0i scvr^ to bo::o^n of outle. tee c bar:.ehow dimensions Nere determmec Comments trecommendanon for pumping. Pvr+tln�ono inlet,and o,ttet t liquid level inrelat,on<to outlet invert,•structural integrity, evidence di leakage. etc., GREASE TRAP: a. . (locate on site plan; Depth below grace /_F-_bej'1; Material of construction: _concrete metssPolyethylene_atker(expla�n? Dimensions: . Scum thickness:_. Distance from top of scum to trip ci outlet tee or baffle. . `Distance from bottom of scum to bottom of outlet tee or baffle: - Date of last pumping: � Comments: r IG (recommendation for pumping• condition of i'ilet and out tees or{baf(le� depth of liquid"level in relation to outlet inveR,.stru(tural integrity, evidence of leakage, etc.; SUBSURFACE SEWAGE DISPOSAL SYSTEMINOECT10% POR.M/ ` PART C n SYSTEM INFORMATION (continued)`.' Property Address: Ow ner. 5> Date of Inspection: v TIGHT OR HOLDI%G TANK:_ '"rank must be,pumped p►iof to of at time,of inspection (locate on site plan, Depth below gee Material of construction. concrete —metal Fiberglass Polyethylene"_other(eapla t►) ti"` w r Dimensions. Capacity Design floN gaho►+a�da, ,.._.. ' Alarm level Alarm in %orking order Yes. `No Date of previous punpinS w Comments ; (condition of inlet tee. condman oT warm and float switche_. etc.) DISTRISUTIO% BOX: iloca:e on site p:a- De.th o'• licuid+ Ie,e! aao%e ouae' in.e= irate tt Igve! 4nd distribjvon is ecua' evidence of solids cam-ov ►.'evide ice-oi leakage into of out of box;etc.) PUMP CHAMBER. ' I:, p(locate on site Ian.Pumps in working order: iYes or No° Alarms in working order (Nes orNo Comments:(note condition of pump chAmbei, pondit�opurtenances, etc.) • e ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert? Addrrss:(A C �e2C•.� • t. Owner: Date of Inspection: B �. SOIL ABSORPTION SYSTEM (SAS); ' (locate on sne,plan, if possible, gxca_1_.ion not requited: but may be approximated by non-intrusive methods, ry If not determined to be present,explain: Tye. leaching pits. number..,6,1&1,0 leaching chambers. number: leaching galleries. number: leaching trenches, number.(ength: ` leaching fields, number. d a7s o^s v : _ overflow cesspool, numbe f Alternative system _ { Name of Technology Comments ` 5 .� •a ' ��-,` mole condition o{bOii. s g*s of h.drawlic-failure. lever of ondin co ds n vegetation etc.(. .. Ir CESSPOOLS: .�- [locate on site pla^ Number and canisgura:,o^ Depth-top of liquid to inlet mver, Depth of solids laver °t / itp �`d depth of scum laver Dimensions of cesspoo: ! Z— t 'x'�materials at construs(!a b, �, "`.;-? ' ' . ,' , ,. ,. m • -. � Indication of groundwate• t inflow (cesspool must tie pumper as par .of inspection,,, • ''" Comments: Ingt;e condition of sat signs of,hydraulic-failure, level of ponding, onditi of v tation.etc. t t �5OIto 1 'I NA . M (locate on site plant Materials of construction ' v s, Dimensions Depth of solids:� t �. • x ;}£, Comments: (note condition of soil, signs of^hydraulic failure, level of ponding.Condition of vegetation; etc.) • ti (revined 01/25/571 Y�g• 8 ol..YO " .. � � ay,t ... . F♦ .. y lea � - .. T- SUBSURFACE SEWrACE DISPOSAL SYSTEM INSPECTIONJOR.M PART C SYSTEM NFORMATION (continued Propert` Address: a �.,N + O%ner: p Date of Inspection: r.• .ram -t SKETCH OF SEWAGE DISPOSAL SYSTE?vl ' include ties to at least two permanent references landmarks or ban6garks locate all welts within 100' !Locate where public water supply comes into house) - _ f � i y_ w t s , „ Y. A' .[ , SUBSURFACE'SEWAGE DISPOSAL SYSTEM'INSPEC 10%. FOR4 C PART t g;SYSTEM INFORMATION (continued)• `. Pro ert. AOrese P � 1 I .• Owner: t� c Date of Inspection.: y Depth to Grtun ate•_?U Feet e- _ Please indicate all the methods used to determine High Groundwater Elevation: . Obtained from Design Plans an record Observation o-*Site uttrng property. observation hole.' basement sump etc.) Determine it from local condition: Cnecw %%ith local Board o• nea!:" CheC� F;�1A ntaRs ,� u . Check pumping ►ecoros v Check local exca,ato•s rr.sialle•s Lie SCS Da:o p r• a _.. '.3.4 - • �e Describe in +ors o� : _+- � arC� ro•.+ +o es.aol!�hec me HighCrounoMa1e.. ElevaUori. IMust be completed k)y,t,"k 6i 0�t ArT I ID SU ,N4`;`tu t., , Teo��r�l �ca�,v.�',A r. b t :C 21tr�bex�c� 1.w1 o-ba v,<— Aura " k , , "'a .. �' } .:• �~ .:,fir.. -•,`.. • • - h" r . - A,