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Home My WebLink About0012 INDIAN HILL ROAD - Health 2 Indian Hill load Barnstable P _ A = 336 010 d � Y Is Is . a a v ^ , .. c o o 4 0 a ° O a , , a , t a4 it i. •Q .. ... � r x ve No. . Fee THE COMMONWEALTH OF MASGACHOSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MIASSACHUSETTS Yes ZIpprication for �Digpogal bpgtem Congtructiott permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon ❑Complete System ❑Individual Components Location Address or Lot No. r�t (�1'" �p Owner's Name,Address,and Tel.No. Assessor's Map/Parcel " 4' —� 3 "D ® 0191V11 Installer's Name,Address,and Tel.No. /° ; l Designer's Name,Address and Tel.No. AJL�- Type of Building: (lQr v�l r 4 f o-r- e"?f Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided. gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r, rn SVACJ1,0 UWpGd d 41/) OA vv Date la inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate.of Compliance has been issued by this Board alth. Signed Date Application Approved by Date / 0 Application Disapproved bp: Date for the following reasons Permit No. 2_00 Date Issued [ /% d xL Fio. 00 � E' Fee . 1 3 a i� ` � , ( ` Entered in computer: TF�E COMMONWEALTH OF MASEF$AC��HI�JSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,-MASSACHUSETTS 2pplication for �Dioogal *proem-Cou6truction Permit Application for a Permit to Construct Upgrade Repair U Abando pp ( ) p ( ) pg n( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 a ��#r7 �po Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel 3 Q 0 f —T Ny of)(A1 Installer's Name,Address,and Tel.No. �r �� Designer's Name,Address and Tel.No. " e of Building: J� -® air t Dwelling No.of Bedrooms P Lot Size sq.ft. Garbage Grinder ( ) Others- Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpcl\ Plan Date Number of sheets Revision Date Title { Size of Septic Tank ` Type of S.A.S. r 4 Description of Soil F Nature of Repairs or Alterations(Answer when applicable) / d m or o 4 o .S/ 1'7`!.. e: i /n 6 U/ 'tn/ i^ �a i•� :� /n �P r - i Date lalt .Q uy Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board alt . Signed pp Date Application Approved by ` Date /1 d 7 Application Disapproved b Date for the following reasons Permit No. a60:7' I S.6 Date Issued y °! d 7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance CAbandon ICI• S TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgradede )by l o S I II 1 __; d A 4.4 7 1/ ;(P has been constructed in accordance -7 with the provisions of Title 5 and the for Disposal System Construction Permit No. d,& 7 >S- dated ✓/�� Installer Designer #bedrooms Approved design flow D gpd v e The issuance of this permit 71nle.W �btrued as a guarantee that the syste ' 1 lnction as designedfDate 0 Inspector 2/;j ,k . ----------- : -----_—.----- ----- —Y�--- — No. 2647 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lie;pogal *p5tem Cou5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ) �. System located at and as described in the above Application for Disposal System Construction Permit.The applicant recogni es his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Con struction must be completed within three years of the date o; hat/t s permm. Q Date LI' ('r'id 7 Approved by e h f Parcel Detail Page 1 of 3 qwo STAULL- MUM •, qL� ,a`1Fi'S4 ,may 5 lcb i T r �-�" '"n',#, "`,�' • t tt c"4 k J �".'>�-Y`-.F...:rr , ,. ,�r .�°` Logged In As: _ r'Ce I deta I - �-_Thursday, Ap Parcel Lookup. arcelInfo Parcel ID .336-010 Develop t I LOTS 1 & 3 Location 12 INDIAN HILL ROAD 7 Pri Frontage 208 ~� Sec Road INDIAN TRAIL Sec 105 - - Frontage -- - village iBARNSTABLE Fire District' BARNSTABLE Sewer Acct; I Road Index 0759 Interactive Map ,i � Owner Info Owner COLLINS ROBERT F & JUDITH M :I Co-Owner %COLLINS, TROY & ISIL Streetl 12925 MAIN ST I Street2 City,BARNSTABLE I State MA '', zip CO2630 Country FUS Land Info Acres 10.49 Use 'Single,Fam MDL-01 -I zoning RF1 Nghbd 0110` Topography Level Road Paved Utilities Public Water,Gas,Septic Location Construction Info Building 1 of 1 Year Roof Ext Built 11956 „-_�I Struct Gable/Hip I wan Clapboard I Effect j 1714 I Roof As h/F GIs/CmP AC None Area•- --- -- CoverInt - P -- - Style Cape Cod wan f Drywall - ' Rooms 3 Bedrooms w Int Bath Model iResijentiai Floor Hardwood Rooms 1 Full Grade Avera e Plus Hot Water 6 Rooms i I 9 Heat[�- Total Type( Rooms _ - � � {r• ;;,. http:Hissql/intranet/propdata/ParcelDetail.aspx?ID=28219 4/19/2007 i Parcel Detail Page 2 of 3 BMT[4'BOI caQ Q 1p�"' BAS p` '`UAFT., 16` `r.lpr Heat Found- 40:' Stories!1.3 Stories Oil Conc. Block Fuel - _ ation --- Permit History Issue Date Purpose Permit# Amount Insp Date Comrr 7/30/2004 New Windows 78340 $50,000 1/26/2005 12:00:00 AM Visit History Date Who Purpose 1/26/2005 12:00:00 AM Martin Flynn Drive by inspection only 3/10/2004 12:00:00 AM Gary Brennan Data Mailer 2/26/2004 12:00:00 AM Paul Talbot Meas/Est 5/16/2000 12:00:00 AM Paul Talbot Meas/Listed 7/15/1991 12:00:00 AM MQ Sales History - Line Sale Date Owner Book/Page Sale P 1 10/29/2003 COLLINS, ROBERT F &JUDITH M 17859/158 2 8/15/1990 BOOTH, NANCY T 7275/317 ; 3 8/15/1990 STORRS, MILDRED L 7275/316 4 STORRS, MILDRED L P-0539E1 5 STORRS, MILDRED L 2339/75 . 1.6 1/31/2007 COLLINS, TROY& ISIL 21743/193 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parc( 1 2007 $158,500 $2,500 $0 $291,100 2 2006 $142,800 $2,500 $0 $275,100 3 2005 $129,100 $2,400 $0 $253,300 4 2004 $114,100 $2,400 $0 $217,100 ; 5 2003 $99,600 $2,400 $0 $154,400 ; 6 2002 $99,600 $2,400 $0 $154,400 ; 7 2001 $99,600 $2,400 $0 $154,400 ; 8 2000 $77,200 $2,300 $0 $75,000 http://issgl/intranet/propdata/ParcelDetail.aspx?ID=28219 4/19/2007 Parcel Detail Page 3 of 3 l r , 9 1999 $77,200 $2,300 $0 $75,000 1 10 1998 $77,200 $2,300 $0 $75,000 11 1997 $85,800 $0 $0 $60,700 12 1996 $85,800 $0 $0 $60,700 13 1995 $85,800 $0 $0 $60,700 14 1994 $87,600 $0 $0 $60,700 .15 1993 $87,600 $0 $0 $60,700 16 1992 $99,800 $0 $0 $67,500 17 1991 $76,300 $0 $0 $82,500 18 1990 $76,300 $0 $0 $82,500 19 1989 $76,300 $0 $0 $82,500 20 1988 $72,500 $0 $0 $43,800 21 1987 $72,500 $0 $0 $43,800 22 1986 $72,500 $0 $0 $43,800 Photos http://issql/intranet/propdata/PdreelDetail.aspx?ID=28219 4/19/2007 K No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, IMASSACHUSETTS Yes Yication for 3i� ogal aem Cow5tructiott er . Q �� p � mtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon W 0 Complete System ❑Individual Components Location Address or Lot No. l a ::�JDi Atj 14111 Owner's Name,Address,and Tel.No. 79-a y Ce/A( l MA4Aa0�'D MA Poo ft< l®N'r Assessor's Map/Parcel " e / I� mA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: ? ,, Dwelling No.of Bedrooms l Lot Size d0j A/sq. fr. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil .i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: R The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H or Sig Date Application Approved by Date Application Disapproved by: Date for the following reasons on Permit No. Date Issued \O� •- a� • • 4.� �` yin. ^ -�, �-��I"�M`: . � • ••. r..T. 441c, No. ��//JIJJ Fee 1 THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Yes j 2 Yication for Dig -o.5al $tem Con.5tructton errrYi 0 p t Application for a Permit to Construct O Repair( Upgrade( Abandon,(+ ❑ Complete System.❑Individual Components Location Address or Lot No. �a pr' (f Owner's Name;Address,and Tel.No. 7�oy c-11 rN� Assessor's Map/Parcel� 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. f Type of Building / � 5 Dwelling o.of'BedcoomV9/`',7_.,r" Lot Size aojpK At"sq. ft. Garbage Grinder ( ) Other Type of Building C No.of Persons Showers( ) Cafeteria( ) Other Fixtures`� - _ _/1+/7'/if Design Flow(min.required) / /'f f �' Design flow provided i r �"" A gpd- Plan Date 11 . +f lrrL�Y f/i,+,!Number o(sheets Revision Date l Title " / az _r� , Size of Septic Tank _ -'A Type of S.A.S. Description of Soil !!!5 y Nature of Repairs or Alterations(Answer when applicable) ,r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of althr. Sig Date Application Approved by ,U y Dace Application Disapproved by: Date U for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Aban o ed(�/ by X�0- at !/ . (1V1WMQhas been constructed in accordance { a� -with the provisions of Title 5 and the for Disposal System Construction Permit No. W dated Installer Designer #bedrooms Approved design flow 1 J gpd The issuanceof t s p it shall not be construed as a guarantee that the system 1,t nction assJdesigne� /Date ( 719 Inspector ————— AT No. l�. Fee ——— r THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION-BARNSTABLE; MASSACHUSETTS migoar *P.5tem Construction Permit Permission is hereby granted to Construct ( ) . Repair ( ) Upgrade ( ) Abandon ( ) System located at I br Hilt t pm IOtJIp and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction st b com ted within three years of the date of thi erm t. Date ( Approved by y � ♦ rl s � s ►_ -&ITF "' aw " + r'_ .ill IL w r '► y _ r` -'�yr. '•��__ - COMMONWEALTH OF MASSACI�iUSETTS c, ExECUTIVE OFFICE OF'ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL_ SYSTEM FORM PART'A CERTIFICATION s Property Address: 12 Indian 'Hill Road Cummaquid . ✓�.G -Q.��. Owners Name: Robert Collins x. Owner's Address: PO Box 2 6 garnstatJ1 Date of Inspection: /,*& Name of Inspector:(please print) Sean .Jones__ Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 �_ y Centerville. MA Telephone Number: (5081 775-8776' CERTIFICATION STATEMENT 1 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 DEI', approved system inspector pursuant to ection 15.340 of Title 5(310 CI11R 15.000). The system: Passes Conditionally Passes -Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ` Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health% 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 scot to the system owner and copies sent to the buyer,if applicable,and the approving authority. Dwet l,� e a Strve� by � Ce55P� +�'r Notes and Comments ( cl 1s M Gk,1r4,.+ want µ� (@tl�.rk..en*S u�L ►'tic.' t�w� c>� !,`�crtisd�bte Q®uvt o� HleG.l�. �,,�l1:,.5S �tw. ✓nvQ�er� �intc /0 ao�3 ""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 L Page 2 of I I r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM F PART A CERTIFICATION (continued) Property Address:_12 Indian Hill Road Cummaauid Owner: Robert Collins Date or inspection: p gosh Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. Passes: 7have not found nun any Information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR'15�31)4 existWy.failure criteria not evaluated are indicated below. Comments: 5 B. System Conditionally Passes: 1\ //A 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 cxfiltration 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: W Observation of sewage backup or break out or Idgh static water-level in the distribution box due to broken or obstructed pipes)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 obsvuctr d pipc(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is n=ovcd ND explain: i r3 Page 3 of 11 OFFICIAL INSPECTION,FORM- NOT FOR VOLUNTAIRY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) , Property Address: 12 Indian Hill Road Cummaquid - �- Owner: Robert Collins Date of Inspection: p 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: r — Cesspool or privy is within 50 feet of a surface water` r _ 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 withina Zone l:of a public water5 supply. ,J — 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 Goni 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 U Page 4 of 11 =� OFFICIAL INSPECTION FOIIAI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Properly Address: 12 Indian Hill Road Cummquid Owner: Robert C llins Dale of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of die following for all inspections: Yes ✓ as 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 A1A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or.available volume is less than'/,day flow 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 privatc water supply well with no acceptable water quality analysis. (This system passes if(he well water analysis, performed al a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates(hat 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(lie analysis must be attached to this form.) �D (YeslNo)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[tie Board of Health to determine what will be necessary to correct the failure. E. Large Systems: Al To be considered a large }stem (he system must scrvc a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes'or"no"to each of the following: (Tlie following criteria apply to large systems in addition to die criteria above) yes no tic 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(Interun 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 die system is considered a significant tlueat,or answered ..yes'in Section D above the large system has faikd.Tire wA-ner ar operator of"large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIK 15.304.The system o%Nwr should contact the appropriate regional office of the Department. 4 I Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 Indian Hill Road Cummaguid F Owner: Robert Col i s Date of Inspection: Check if the following have been done.You must indicate`yes"oi"no"as to each of the following: ' Yes Nq Pumping information was provided by the owner,occupant,or Board of Health J 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 _ v 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 availablenote as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage,back up? a� a Was the site inspected for signsof break out? s. Were all system components,excluding the SAS,located on site? --Pr 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 occupantsif difTererit-from owner)provided with information on the'proper t. maintenance of subsurface sewage disposal systems? , s 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. - V/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation roximation of distance is unacceptable)[310 CMR 15.302(3)(b))' Pp ' 5 . Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 Indian Hill Road Cummaquid Owner: Robert Collins Date of Inspection: E la ;oo(o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): I* 6PjD Number of current residents: 0 Does residence have a garbage grinder(yes or no): AJD Is laundry on a separate sewage system(yes or no):N'O [if yes separate inspection required] Laundry system inspected(yes or no): AfIN Seasonal use:(yes or no):Mo Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no): MD Last date of occupancy: (D a-0b3 ` COMMERCIAL/INDUSTRIAL A[JAB 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: VAV'uov Was system pumped as part of the inspection(yes or no): "D If yes,volume pumped:_gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system mg le 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: Were sewage odors detected when arriving at the site(yes or no): .,✓_Z� 5 6 Vja c7cfI1 OFFICIAL INSPECTION F010.1 — NOT FOkt VOLUN-I'AItY ASSLSSIIILNTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSI'LC'I'ION I OIt111 PART C SYS'I'EM INFORMATION i(continued-j r a Property Address: 12 Indian Hill. Road Cummaqui Ottncr: Robert. Co ins Date of Inspeetlon: iO e�b BUILDING SEIVEII(locate on site plan) .' , •s Dcptls below grade: J S" Materials of construction:_cast iron, 40 pVC'_✓,Odlcr(explaui): Distance front private water supply-well or suction line: Tom — Curnm�cnls(on condition of juults,venting,evidence of leakage, cic.); ' J®,n 1� wtrc DIE w-c7 5is,� d 1�1G�tj G NfI SEPTIC TANK:—1(locate on site plan): { Depth below grade: 'Malerial of construction:_concrete metal fiberglass tiulyetllylcne _othcr(cxplain) z If rank is metal list age._ Is age cunfihued by a Certificate of C ccrtificatc) ' ompliance(yes or no):—(altach a copy of a Dimensions: Sludge dcpil% Distance irons lop of sludge to butluln of outlet Ice or baflle: Scum thickness: °; t Distancc from top of scum to top of outlet icc or banlc: Distance Gosn bonons of scull to bollonl of outlet(cc or battle: lo%v were dimensions dctennincd: t Comments(on pumping(ecolnmendations, inlel and outlet tee or baflle condition, struuwal inlegrity,liquid Icacls as related to outlet usvcn,evidence of leakage, c(c.): GIIEASE TRAI': Olocatc on site plans) Dcptls below grade:_ Malcrial of construction:_collcrctc Inctal fiberglass_pul�-ctll)•fcnc other (explain): — — , . Dimensions: -- Scum Illickrscs Distance from Iop of scull to tup of outlet Ice or balllc: Distance front button) of scum to buttuin of outlet ice C.r battle: Date of last pumping: Conuncnis(oil pumping Icconuncndmlulls, inks and uutict tcc of baffle cundlllo:l, slluctulal m1cg111)', liquid (gels as rclalcd to oullcl insert, ceidcnec of Icaki�c, etc.): 7 I, 'age 8 of I I ,• OFFICIAL INSPECTION DORM - NOT Il Olt VOLUNTARY NTAItY ASSL:SS111EN"I'S SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORS i PART C SYSTEM INI'OlU1A'CION(cunlinucd) Properly Address: 12 Indian Hill Road Cummaguid Owner_ R rt Collins Drsle of Iaspecllon: 5 e0 a n TIGHT or HOLDING TANK:� tasdc must be pumped at time of inspection)(lucate on site plan) DepO►below grade: Material of construction:^concrete_metal_Fiberglass___pulyelhylene o►het(explaut): Dimer,sions: Capacity: -alluns Dcsign Flow: gallonslday Alarn• present(yes or no): Alarm level: Alarm in working order (Jcs or no). Date of last pumping: — Comments(condition of alarm and float switclres, ctc.): DISTRIBUTION BOX: LA(if present must be opencd)(locate on site plan) Dcp4i of liquid level above outlet invert: _ Co►rdnen(s(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,cic.): PUMPCRAMBL11:41lucate on site plan) Pumps in working order(ycs or no):— Alanns in working order(yes or no): __ Cununcnts(nolc condition of pump chamber, condition of pump; and appurlcnanccS, ctc.): Page 9 of OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK . PART C _ SYSTEM INFORMATION(continued) . Property Address: 12 Indian Hi-11° Road -; Cumnlaquiff Owner: Robert Collins Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: - t Type leaching pits,number: leaching chambers,number: . leaching galleries,number. leaching trenches,numbci-jength: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system- Type/name of technology: Comments(note condition of soil, signs of h}`draulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS:Zcesspool'must be pumped as part of inspection)(locate on site plan) Number and configuration: C0,1&4 z Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. 4 - Dimensions of cesspool: /4ppiv,z. $�(0' f ` Materials of construction: CPAye4e, alacit Indication of groundwater inflow(yes or no): Na CommLenits(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.): v49.�ifa TAW L,--.S Aft,r p.! / �77 �CCw O✓ �/�l'L 'I�l�✓� �6/� frG$ Gl/'L� �c �P fOrrN�. ,tss�afl/s r�crr c,(� `r�� P�a,:,� �� t,,,G,•kr: .. 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.): Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM : PART C SYSTEM INFORMATION(continued) PropertyAddress: 12 Indian Hill Road Cummaquid Owner: Robert Collins Date of Inspection: /t o/ oDto SKETCH OF SEWAGE DISPOSAL SYSTEM Ih 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. l2 CA OF 1400Sa I �R Ceupco1 1 - 3, 6,° 8%9;= 3 ° 10 I' .Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Indian Hill Road F _Cummaauid Owncr. Collins Date of Inspection: SITE EXAh1 Slope Surface water Check cellar Shallow wells Estimated depth to ground water 0 feet Please indicate(check)ill 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: (�cU,rr� we.•4�r ircJ .^a9f' tiJ �+` e�wc -dti. vF AST I P—t-,k 4-a Ponce r� \ COMMONWEALTH OF MASSACHUSETTS 11 1 ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . I' ! I ir DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 12 Indian Hill Road FCT 2 1 2003 Cummaauid Owner's Name: Nancy Booth TOWN OF BARNSTABLE Owner's Address: HEALTH DEPT. a _ . Date of Inspection: J0 Name of Inspector:(please print) W i 1 1 i am F_ • Robinson Sr. MAP Company Name: William E. Robinson Septic Service PARCE4 .1 fit® Mailing Address: P O Box 1089 Centerville, MA L0? Telephone Number: ( 5081 775-8776 CERTIFICATION STATEMENT I certify that 1 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: f/Yasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _L', �� _ Date:lU—ld—d The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 Indian Hill Road Cummaquid Owner. Nanr U Rnnth Date or inspection:-&--/5=-Cs Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 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 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): 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 obstmx1ed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is mwvod : y= ND explain: 7 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A a CERTIFICATION(continued). Property Address: 12 Indian Hill Road Cutntnaquid Owner: Nancy Booth f } Date of Inspection: lJ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Y�s 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 groundwater elevation.. — Any portion of cesspool or privy is within I004eet 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 Katrr 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 or the analysis must be�attached to this form.] (Yes/No)The system fails. 1 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: Lar Systems: - To be con idered a large system the system must serve a facility with.a design*now of 10,000 gpd to 15,000 . gpd• r You must' dicate either"yes"or"no"to each of the following: (The folio g criteria apply to large systems in addition to the criteria above) yes no the ystem is within 400 feet of a surface drinking water supply the s stem is within 200 feet of a tributary to a surface drinking water supply the s stem islocated in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped Zon 11 of a public water supply well If you have an wered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Secti'n D above the large system has failed.The owner or operator of any large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The ystem owner should contact the appropriate regional office of the Department. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 Indian Hill Road Cummaduid Owner: Bootb Date of Inspection: Ctr—)S 0-3 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 fail g to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is f nclioning in a manner that protects the public health,safety and environment: _ e 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. e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a privatt water supply well** Method used to determine distance "Th4s system passes if the well water analysis,performed at a DEP certified laboratory, for coliform ry ybactria and volatile organic compounds indicates that the well is free from pollution from that facility and resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other e criteria are triggered.A copy of the analysis must be attached to this form. 3. (her: 3 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 Indian Hill Road « . -Cummaauid z Owner: Nancy Booth Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for'example: 110 gpd x N of bedrooms): 0 Number of current residents: Does residence have a garbage grinder(yes or no):,&—,0' `. Is laundry on a separate sewage system(yes or no):/tiO [if yes separate inspection required] Laundry system inspected(yes or no):1u� Seasonal use:(yes or no): ` Water meter readings,if available(last 2 years usage(gpd)): 2001 -2 9.0 0 0 Sump pump(yes or-no):�J` 2 0 0'2-1 6 '0,0 0 Last date of occupancy: l0 COMMERIO ALIINDUSTRIAL Type of estab ishment: Design flow()ased on 310 CMR 15.203): gpd Basis of desiE a flow(seats/persons/sgft,etc.): Grease trap p esent(yes or no): Industrial wa to holding tank present(yes or no): Non-sani waste discharged to the Title 5 system(yes or no):_ a Water mete readings,if available: Last date occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: /Q Fi' Was system pumped as part of the inspection(yes or If yes,volume pumped:/Vt-6 gallons--How was quantity pumped determined? Reason for pumping: -1-ti F- 3 ,el�.�" TYPE OF SYSTEM ~ _Sep is tank,distribution box,soil absorption system t . _ gle cesspool Overflow cesspool _Privy f. _Shared system(yes or no)(if yes,attach previous inspection records,lif any) _Innovative/Altemative 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)andsotrce'of'information: Were sewage.odors detected when arriving at the site(yes'or no):LcJ . .. 6. { Page 5 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 Tnclian Hill Road Cummaguid Owner:_Nancy Booth Date of Inspection: /&--IJ—o 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? 21Have 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? 01 G _ —/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)j 5 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS`- ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) Property Address: 19 T nd i a n H i 1 ) Road L C"mmac-aid Owner: T�lnnr�v R,,oth ; Date or inspection:lz.,'l TIGHT r HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth bet w grade' Material o construction: concrete metal fiberglass - Polyethylene other(explain): Dimensions Capacity: gallons Design Flo ; gallons/day ' Alarm presc it(yes or no): Alarm level Alarm in working order(yes or no): Date of last umping: Comments condition of alarm and float switches,etc.): m ,, DISTRIBUTIO BOX: (if present must be opencd)(locate on site plan) _ Depth of liquid leve above outlet invert: Comments(note if b x is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out o box,etc.): + i PUMP Cjwork-inordcr R. (locate on site plan) Pumps iyes or no): Alarms i (yes or no): Commenn of pump chamber,condition of pumps and appurtenances,etc.): R Page 7 of I 1 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP OSALSYSTEM INSPE CTION .ON FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Indian Hill Road _Cummagtt i d Owner: _Nancy Booth ` Date or Inspection: /v—ti_e 3 DUI LNG SEWER(locate on site plan) Depth Blow grade: Mater Is of construction:_cast iron _40 PVC_other(explain): Dista cc Gom private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TAN —(locate on site plan) Depth below gra e: Material of const ction:_concrete metal fiberglass_polyethylene _othcr(explain If tank is metal lit age:_ Is age confinned•by a Certificate of Compliance(yes or no):._(attach a copy of certificate) Dimensions: Sludge derensions Distance G sludge to bottom of outlet tee or baffle: Scum thic Distance G scum to top of outlet tee or baffle: Distance from of scum to bottom of outlet tee or bane: How weredis detcnnincd: Commenting recommendations, inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as relatedvert,evidence of leakage,etc.): GREASE T P:_(locate on site plan) Depth below adc:_ Material of a swction:_concrete_metal fiberglass____polyethylene_other {explain): _ Dimensions: Scum tllickn ss: Distance Gor-top of scum to top of outlet tee or baffle: Distance Go t bottom of scum to bottom of outlet tee or baffle: Date of last�umping: Comments Eon pumping recommendations, utlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Indian Hill l Road Cummaduid - Owner: Nancy Booth Date of Inspection: 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. 10 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Indian Hill Road Cummaquid Owner: Nancy Booth Date of Inspection:_6 -/ —<> SOIL ABSORPTION SYSTEM(SAS): L/ (locate ou site plan,ezcavation"not required) If SAS not located explain why: Type r. leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: thing 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: -6 `v '9 Depth—top of liquid to inlet invert: 42-/ 0 Depth of solids layer: / r' Depth of scum layer: Dimensions of cesspool: of Materials of construction: e►G 6 Indication of groundwater inflow(yes or no): Comments(note condition of soil, ns of hydraulic failure,level of ponding,condition ooffvvegetation,etc.): PRIVY: (1 cate on site plan) Materials of con truction: Dimensions: Depth-of solids: Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - Property Address: 12 Indian Hill Road Cummaquid Owner. Naacy Booth Date of Inspection: 'U— —b SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: x Obtained from system design plans on record-If checked,date of design plan reviewed: ,"bserved site(abutting property/observation hole within 150 feet of SAS) ✓Checked with local Board of Health-explain: a L g Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must de cribe how you established the high ground water elevation: . 11 + T ri 1: ' '. ,,r 1 s� T t tys�) 1 :i5 3" '.'p .j{* { 1i ��i zra"f;�3 xr3:: 1 s! �` i 1 t � T �—.. t -1 ✓ f ,�..._ --- vjit CA y r+. , ,Jk t 4��r. . p -�! ,apt to��s �` 1 i! i��TYt(`7r;�,�•,$ i q i�t�� s, ; �n17'. J. r - e W 1 - t w i i,- ..i �.• � � t. I rz POOR,.�. h .. .... Row-, It �Ira�RR'P,-ru �, CaLL,'�5 N^r IaZ i7ofax i l( `(7.13.. C.r:.r ° 1 rl APPROVED 9V: W ' .. DATE `'. E. .61' - - - OR q'•NING NUMBED i R 1,44*11 i Y cp � PROP. ADD'N. S�nq lK s �1dv�r 157.56' 42.00' zo 48.99 + 0.9 f , /.- +36.24 + CESSPOOLS '� o +43.31 p 2� 10 � 0 21 +3, ; ' r 6, - - 69 -}-36,13 18.7' N J '.. + - 41 _ O EXISTING N Z }-42:19 40.DWELLING, P �—�-40 37 14 LOTS 1 8c 3 TF-43.85 20,804 SFt 18s�Q' . 4 i 39.87 4- 41 +4:" 8 PAVED p� DRIVEWAY 1+ 35 4 } 42,37 38,59 +,a;777 mCO +40.58 4 3 t ,� �� 3 7.8 3 v�� - 3 5: 40 _6.04 35.96 z 85.83 f ` 5 b] 33.9 33,9 7 - 33.77r- v 33.91 WORKPLAN OF LAND IN CUMMAQUID, MA PREPARED FOR TROY COLLINS SCALE: 1" = 20' ° � . •;r JOB # 04-161 JANUARY 8, 2007 µ I • I _ ' I 20a-7 PROP. ADD'N. Sin_y lJ�^ Jd - 42.00' ' � .20 o 9 •J j 30 2 4 CESSPOOLS: +43.3 ;3.25'+4j 05.4' 10 2 +36,6536.13 � 18.7' �e * -{- 41 on EXISTING ^, D WELLI N G 4 0 .4 LOTS 1 ;& 3 r TF- , P a -+40 37 20 --� ' 43.85 f' ` ,804 SF p , 5 07 4�i 39.87 Ln a +4 8 PAVED , DRIVEWAY .+3 3b.7 7 co 5 38.59co /. + 0 • 4 0.5 8 4 3 , ,� � � Inv* 3 7.8 3 40 Y. • 6.04 s F 3 5.96 • a 2 a " 5 33.9 33:97 �3317 �e 4r Ro Ao WORKPLAN OF LAND IN CUMMAQUID, MA PREPARED FOR TROY COLLINS : SCALE: 1" 20' a E JOB # 04-161 ,.- JANUARY 8, 2007 F _ r,- (1( • . 1 • a b , t :11 , • ?lF1t'¢•C,,_ I �a��.�i .� ?�y�L�-�i �a. � R �/ tip- .. �` ��'�, !� '.1 R ib` �� — • 1 / V ,d: 4' : , f P _ J F /�/1 } ,.,i 1. �'.(-•-x'-' 7 �_ n n r e 4� j"Al ore • r 77 . 1. - �—. -i. L :�.. L_ - 'Yf� tea. } t,.••!t Cf k W Y { : , .. •� � -;.\.m: i.. -:i ,' (.__—_.._� c q9'r i. I _ -—+; � - —c---,-,••^` - .1� fix! /: S s ` a• 1 { , cJ 4 L i. �. _ _ • 4 . _ � � sum •h �l� ` . <-- ,�.. ,. .,,, �� J' { ..:. ;. ., .. r ;>,! .,.:'.Ai RS - +. ��• is " i` '.h.' y q, • , r w Y ( ff - G i • Y x J r .. - w ✓1 V _ J yy �.r ,...�."._..,_n.i�n+, :r�,7 • !' IV(C- ILCxt \,t:.� - 33 � s . a n ., -.P a$�x.f'. .../vt� n , ' -SCALE DATE: '� APPROVED BV. - DRAWN By DATE t, f'7 07 `tz t�1 DRAW 6 MBEP x^^�