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HomeMy WebLinkAbout0218 OAKMONT ROAD - Health 218 Oakmont Road Barnstable. .P � -� A.=. 334 .055 .J Z. I i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaguid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road Barnstable MA 02630 October 25, 2011 . page. City/Town = State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, O n� use only the tab 1. Inspector: key to move your U cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections ` VQ Company Name 19 Hummel Drive Company Address - South Dennis . MA 02660 City/Town State Zip Code (508) 385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: as 1 c U' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority L c� �l i(l,c ,�.�,,•-=� October 25, 2011 �- Inspectors'Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under A the same or different conditions of use. t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Form -Not for Voluntary Subsurface Sewage Disposal Systemo Assessments 218 Oakmont Road, Cummaguid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): N/A t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 • Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaquid M-334 P-055 Prop"Ad dress ddress Neil&Jocelyne McLean a Owner Owner's Name information is required for every 218 Oakmont Road Barnstable MA 02630 October 25, 2011 page. CiVrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval'of Board of Health): ❑ ' broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed,pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR , 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment:, ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. C4rrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaquid M -334 P 055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is 218 Oakmont Road Barnstable MA 02630 _ October 25, 2011 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain.of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system'is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim,Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25,2011 Ci page. tY!Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usa e, 10=179,000 gals. g ( y g (gPd)) 09=109,000 gals. Detail: - I Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date CommerciaUlndustrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A - Gallonsper day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap.present?, ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped in August 2011 per info from home owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaquid - M -334 P 055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 10/5/88 per compliance Were sewage odors-detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet- Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene - El other(explain) If tank is metal,,list age:_ - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'Xg'X6' 1000 gallon Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2' 8" Scum thickness none Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): N/A Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A N/A Dimensions: N/A Scum thickness Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A N/A Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,.. y 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name - information is required for every 218 Oakmont Road Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)­' Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material ofconstruction: El concrete ❑ metal a-° ❑fiberglass El polyethylene ❑other(explain): N/A Dimensions: N/A Capacity: - N/A gallons Design Flow: N/A gallons per day Alarm present:. ❑ Yes ❑ No Alarm level: `Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A x, *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaquid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaguid M -334 P-055 Property Address Neil&Jocelyne McLean Owner owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -6'X6' pit with4'of stone ❑ leaching chambers number: ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic.failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found with 2'of water present with a visible stain line approx. 2' higher. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Inlet line enters through riser. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaguid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•11110 Tite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaguid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A i 1 I 30 Ile.7,0 . 34 I I l • Ss ' t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Oakmont Road, Cummaguid M-334 P-055 Property Address Neil &Jocelyne McLean Owner Owners Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 8/7/86 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: AIW 247 Zone C 23.7' 4.0'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 13.0' at a lower elevation. USGS groundwater maps show groundwater at approx. 44.7'. Groundwater adjustment at the time of inspection was 4.0'. Bottom of leaching at 13.0'was found not to be located in the high groundwater elevation at the time of inspection. Past inspections also determined that leaching was not located in the HGWL. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Oakmont Road, Cummaguid M-334 P-055 Property Address Neil&Jocelyne McLean Owner Owner's Name information is required for every 218 Oakmont Road, Barnstable MA 02630 October 25, 2011 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 h COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION p a oqM SVev \ V I TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ` PART A CERTIFICATION Property Address: 218 Oakmont Road �J ✓ Barnstable MA i Owner's Name: Peter& Rosemary Whiting Owner's Address: P.O.Box 1115 Barnstable, MA 02630 Date of Inspection: 04/24/08 Name of Inspector: (please print) Mr.Carmen E.Shay = -, 1•. Company Name: Shay Environmental Services; Inc. (nk ; Mailing Address: 185 Ashumeet Road 5;1 Mashpee, MA 02649 Telephone Number: (508)-539-7966 , CERTIFICATION STATEMENT 3 I certify that I have personally inspected the sewage disposal system at this address and that the info at ion reported. below is true,accurate and complete as of the time of the inspection. The inspection was performed b ed on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes Conditionally Passes OF AR, \v sin Needs Further Evaluation by the Local Approving Authority, . Fails V C i— EN o E. Inspector's Signature K " SI IAY p g C-1— �;h1 � Date: 04/24/08 0 � T1F�� <<c� The system inspector shall submit a copy of this.inspection repo the Approving Authority(Board of H h�P DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10, 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 No evidence of hydraulic failure from leach pit. Excavated Pit Cover and noted 36" liquid in pit. ****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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04,124/08 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or 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 obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: „.,. 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 218 Oakmont Road Barnstable,MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no'to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or. clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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. IThis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.1 No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board.of Health to determine what will be necessary to correct the failure.. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I W PA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04i24/08 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant, or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX Has the system received normal'flows in the previous two week period `? XX Have large volumes of water been introduced to the system recently or as part of this inspection `' N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX Was the facility or dwelling inspected for signs of sewage back up `? XX _ Was the site inspected for signs of break out? XX _ Were all system components,excluding the SAS, located on site`? XX _ 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 XX _ 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 XX _ Existing information. For example, a plan at the Board of Health. XX 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)] r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd): Sump pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: None Available Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank, distribution box, soil absorption system _Single cesspool XX 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: house built in 1988, Per BOH as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 iL Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:—cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: Cover 6" below Grade Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5' x 5' x 8'— 1,000 gallon tank Sludge depth: 4.0' Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: '/4 inch scum laver noted Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural integrityl was ok. 4" PVC Tee present at inlet end. Outlet Baffle present and in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 f Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Present (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.):_One outlet to Leach Pit PUMP CHAMBER: (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.): T .. .„. 9 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 218 Oakmont Road T Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits, number: 1 leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number,dimensions:_ overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): No evidence of hydraulic failure, pondinp_damp soil or stressed vegetation. Excavated Pit Cover and noted 36" liquid in pit. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): .,.. 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 218 Oakmont Road Barnstable, MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 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. Oakmont Road Water;Line Swing Ties: A- Tank In—34' B- Tank In—30.5' Exist House C- D-Box—43' (3 Bedroom) D- D-Box—39' A B A- -Leach Pit-32' B—Leach Pit—55' Deck O O 1000 gal septic tank O D-Box Leach Pit f A i Page I 1 of 11 • I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 218 Oakmont Road Barnstable,MA Owner: Peter& Rosemary Whiting Date of Inspection: 04/24/08 SITE EXAM Slope Surface water - %: mile+/- Check cellar - Yes Shallow wells—None Estimated depth to ground water Over 75' feet Please indicate,(check)all methods used to determine the high ground water elevation:. Obtained from system design plans on record- If checked,date of design plan reviewed: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Quadrangle of USGS Map,MA GIS and performed GW adiustment calcs. Per Barnstable GIS: Elev.of Ground=85eet Elev.Of Groundwater=25 Feet Elev.Of Bottom of Leach Pit=75 Feet Therefore: 75—25 =50 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well AIW247,ZONE C: 3.6 feet Adjusted Groundwater Separation=50' -3.6 =46.4 feet Grade= Elev. 85feet Leach Pit Septic Tank Bottom of Leach Pit=Elev. 7 feet Adj. Groundwater= Elev. 28.6 Town of Barnstable �p THE T . Regulatory Services BAMSCABM ; Thomas F. Geiler,Director. 9$pT1 A��� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual' number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. 3 COMMONWEALTH OF MASSACHtiSETTS r EXECUTIVE OFFICE OF ENVIROTNITIMEN` -u-AFE_uR,S DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION � Property Address: O ��J/� 0G�v7 on f R 1 cc� w)►�1o�a�,�- � � oa63� E �� Owner's Name: e e, V , i;, ' c Owner's Address: PO .(ToX /I tt + � Date of Inspection: —T ^S=01 Name of Inspector: (please print) 7)C r4- /o�� an P Y Name: E/1/l/i� Company r '— %�G ft Mailing Address: n eo Z. 101CD rn sf 4 tiv"7 4 A, Telephone Number:(SoF �S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: a Bate�_.. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now 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- SP�o f f G D t4 fle -)L— COkCv- hem s �o d 12e,O/A cev� ****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: c� L12 0$n II rM�►tia�, ' oa 6 3� x , Owner: Date of Inspection: 3— Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: I have not f -,found any information which indicates that any of the failure criteria described in'10 CMR 15303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as'described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,N-D)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 obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T41. G inc..nrt nn 1 nrm 411</Irmo 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C A vr�- /Qc::� w / `�.►rM ► Owner (,t/G, ,4 r &17 Date of Inspection: 3 s V-6 Furthe r er Evaluation is Required b the Board of Health: q Y 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 C_-NM 15303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory; for coliform bacteria and volatile"organic compounds indicates that the welris free froff 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: P,,..,, Ali, irmnn 3 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: I Oaf✓v"t9t? �� a m oa c 3� Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No ✓ 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 ogged SAS or cesspool ,/dStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ess ool�e P ✓ below invert or available volume is less than',iz day flow Li id depth in cesspool is less than 6 be o in ert � P P ,,1equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number yf 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. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CIMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) y no e system is within 400 feet of a surface drinldiig 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-?W-PA)or a mapped ne II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a s;Qnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 C-%M 15.304.The system owner should contact the appropriate regional office of the Department. T;tlo G TnC—,t;nn P,rm All Vlnn l 4 Page 5 of 11 k- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �0 �G�/c/7 0�� ��✓ Owner: Date of Inspection: Check if the following have been done.You must indicate"yes or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health v Were any of the system components pumped out in the previous two weeks? v — 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 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 bafflesor tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? `'alas 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 o Existing information.For example,a plan at the Board of Health _ Determined in the field if an of the failure criteria related to Part C is at issue a roximation of distance _ ( Y PF is unacceptable) [310 CVIR 15.302(3)(b)] y T;tlo fnencrtinn TZ,— 411;/1r1M 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: O��✓rr�ro,n Owner• , c✓► Date of Inspection: j— 0-6 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): Number of current residents: O O Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):T_ [if yes separate inspection required] Laundry system inspected(yes or no): O F' �� Seasonal use: (yes or no): /�d Water meter readings,if avail �O/ able last 2 �g > ears usage( Y g (gpd)): Sump pump(yes or no): Last date of occupancy: H irc C O NLMERCIAL/IND USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgtetc.): 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: d A"�Iye C�Pc✓S— 01,..-�� Was system pumped as part of the inspection(yes or no):,� J/�jJ c/ If yes, volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM _Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance cona-act(to be obtained from system owner) Tight tank - Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date ' ttalle(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Title fncnar+inn Fnrm (./1 5/7(1(1(1 6 Page 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLL!-TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 6)G4/v"O-7T / vt V"l N1 Gi Qvt Owner: ✓1 Date of Inspection: —S= 0,6 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: iron _ 0' PVC_other.(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(1`� ocate on site plan) Depth below grade: Material of construction: . -oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) i Dimensions: X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler 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: 9 How were dimensions determined: /�01�e �� - ev/C- Comments(on pumping recommendations,inlet and outl a or baffle condition,structural integrity, liquid levels as fated to outlet invert,evidence of leaks e,etc.): ,kl '-20-/ dJeecJe C�7L ��✓hB� Gti� GHQ /h ov+ i rpt, GREASE TRAP-:/!/ locate on site 1 —( pan) Depth below grade:_ Material of construction:_concrete_metal fiberglass polyethylene_other (explain): a 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 baffler Date of last pumping: Comments (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Titles Incnnrtinn Gnrm 4/1 G/7(1M 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUTITTARY_ASSESS TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINT PART C SYSTEM INFORMATION(continued) Property Address: O� �✓�o+�� ,Q� CIA wrr1 a (2 /� 0016 39 Owner: �A t.1 Date of Inspection: -O TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on'site plan) ' Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: f±/ i sent must be o ened 1 a( pre p )(oc to on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage iTp or out of box etc.): / PUMP CHAMBER: (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 ofpumps andappuitenances,etc.): T;tlu Tncnortinn J nrm (�/1 a�nnn 8 I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSNVIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOWN4ATION(continued) Property Address: �►���.'��•y'. as 6.�� Owner: �✓�/� �- , Date of Inspection• 3 -4 SOIL ABSORPTION SYSTEM (SAS): (Iocate on site plan,excavation not required) If SAS not located explain why: 1-4 Type leaching pits, number: � , leaching chambers,number: /L f leaching galleries,number: leaching trenches,number,'length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments ( note condition of sou,signs of hydraulic failure,,level of pondinCr g,damp soil,condition of vegetation, etc.) P-9 v�C r' .r L!7`/e, S7�;l� �/ '/ ✓r G �o� �� Yl O /G�.. /G i O� CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: " Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs ofhydraulic failure,level ofponding,condition of vegetation etc.): PRIVY: locate on site plan) , Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure,level.of ponding,condition of vegetation, etc.): a Title G Tncnortinn G'nrm 4"1;P noi) _ -- Page 10 of 11 e OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c2 1O Owner: Date of Inspection- — j 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 wAere public water supply enters the building. :w 14 in J ✓� /J 3— C� o c� D 0 J o� . (it�o (neno�tinn �nrm F/1�/T(1(1/1 10 • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c2 le ©o lv%r okj� 0:24 Owner: W r 7 i h Date of Inspection: SITE EXAM Slope / Lf Surface water Check cellar (o1 'n Shallow wells T� Estimated depth to ground water 4/feet Please indicate(check)all methods used to detemvne 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: IQChecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ow you established the high ground water elevation: o _.- �wc�e. rir7� �r lOc I� /3 - 4 r0 l�o � e /p w ram, 4 o wwG�i/cd�y o. o 7 n { 0 o cQ (o ?�l -Z -0 a 1-3 e�Gr m 31, Titto f incncrrinn Fnrm �W � TOWN OF BARNSTABLE LOCATiONr-� 9 18 C�k:►mot.ev-1` 1 -CPAa o SEWAGE# VILLAGE -e, LV ASSESSOR'S MAP&PARCEL " INSTALLERS NAME&PHONE NO. tZT,, M a-L4-2xs-suto SEPTIC TANK CAPACITY O t CJC0 LEACHING FACILITY:(type) '?11r (size) NO.OF BEDROOMS �J 1 OWNER' - PERMIT DATE: I Lq I COMPLIANCE DATE: /8 5-88 Separation `Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4ke . 4 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leachin Facility(If any wetlands exist within 300 feet of leach' gfacility) ►q Feet FURNISHED BY 140MCV.% S AW r `l x4.3 3q r?"r -VA S\S w F BARNSTABLE 0 2-1 9 TOWN O LOCATION SEWAGE # VILLAGE / « ASSESSOR'S MAP & LOTY- INSTALLER'S NAME & PHONE NO, 1YbCA � cjdus ' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ®/%- (size)_ A,900,%d NO. OF BEDROOMS PRIVATE WELL O UB=ij�-TER BUILDER OR OWNER -57.FUF ,2r17X� DATE PERMIT ISSUED: AItt, DATE COMPLIANCE ISSUED: zsx-, VARIANCE GRANTED: Yes No , i 0 3' ,�- M n s `No....an� ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH wt OF.... � /ti/`!...2. d'='''.................•---•--.. Applirntiou for M-4poo al Works Towitrnrtiun ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: •� 'R 11f.......... ......- -/-7--------------------------------------------- L .a on-Address or t Not. Owner Address �1�1; ac��3E2 .. . �®=----------------------------- `! rt2P./ ''/G Installer Address ' `a/ 2 o d Type of Building Size Lot.._. ._-Y-1.. .............Sq. feet U Dwelling—No. of Bedrooms.............................. .. .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons--------.................... Showers ( ) — Cafeteria ( ) a' Other fixtures ----------------------------------- W Design Flow.._.......5�.............. gallons per person per day. Total daily flow...3-3 d......_._............-_....gallo+s. R t ; Septic Tank—Liquid capacity OoD_.gallons Length$_. ___.. Width. _--j6_••. Diameter--------------_. Depth.3'.......... Disposal Trench—No..................... Width.............._..... Total Length............_...... Total leaching area....................sq. ft. Seepage Pit No--------/----------- Diameter....l ...... Depth below inlet................ Total leaching area.!_.?_-.bsq. ft. Z Other Distribution box ( ) Dosingnk ( ) '-' Percolation Test Results Performed by........'. e....... CU.... .... Date-AY 4_....7....1_ 1.4 Test Pit No. 1__4---- _.minutes per inch Depth of Test Pit_f�1__-4._....._ Depth to ground water....`'-__....... f=, Test Pit No. 2___ ,.. ._minutes per inch Depth of Test Depth to ground water._.,_._".................. ----------------------••-•••-......--••...... -------------- O De ri tion of Soil Q �! .4....... ......p- �Am N 'S v -C®fi e. b--� iS 6 �(� U ............... P. �'IML 5�9_N..1?.-----fig `'...... � �'n�, ,L_:._ / �------��-�-----• ---70.. -- �'..!..-- f�^� - � �fJr-� ----1N45—---------------- W �N� 7'ON- '.� N UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T;I }of the State Sanitary Code—The undersigned further agrees not to place the system in operation u o ea ert* a ce has e 'ssu by th board lth. igned- ... ........ _...........------------------ I^I Date Application Approved By............. q, 4 -��` ' ........... Date Application Disapproved for the following reasons:................................................................................................................ •----•---• ..................................................... Date Permit No...........Y..6.44P.................... Issued....................................................... Date �J No...�f':/o...... FEB_. 7.7 ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appfiratiun for llhiposal Works Tonstrnrtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4-17 ......................... .... .............................. .............................................................. o r w.ot No,� owner Addr ss a .tf�o13F2T 7S .V ........ -d � .�.. '�� 2N ..._/�r�2 t✓icfi� •-•--•••- ----..-...-••••••-• •--• - Installer Address UType of Building Size Loty.Y,7.2 .... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) paI Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures . d - --------------------------------------------------•----------•------•.................••••-•---------- W Design Flow.._...._..2�...........................gallons per person per day. Total daily fiow..3.,30..........................__gallons. RS Septic Tank—Liquid capacit�.M�...gallons Length?-S•!.& WidthV..1.,6''___ Diameter................ Depth;._'.$.!_. Disposal Trench—N?o. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.../.Y-_,-------- Depth below inlet...9............. Total leaching areaV./.�__-'%.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---k>V A_1?4. ._....A_t4,4.. ..... Test Pit No. 14._V____minutes per inch Depth of Test Pit��i 6_.��____-• Depth to ground water..�..,.,�----------- P=4 Test Pit No. 24-..y-_-_minutes per inch Depth of Test PitP7.6.`!....... Depth to ground water.._,,........,--_--____ 1:4 ----•- -------------------=----•-•••••.....•••....---•--•-•-•-.......•--------•---•••-•-••-•---•••-•-••...-•----••••-•--•-•-••-••••••...........•----...... O D r�p�iQr� o>1.�?.._'_....?-sa. b -L%J Cl4. 5 u t S o ........... x ! i F 1. i -. 9 _ 1� �, ------ _ - I N ...__.. Aw,�. �6-in--to - �;_._...� :54-•...i>A ,� �A...... l�fa--------- N `S?OnIS 16. Tq ��� �' 1�? l� Finl1� 3�N� lT �is--------------•-- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------•-•--•-----------•----•--•-----------•••-•--•-••••........•-••----••-•--••-••-•-••••-•••...•--••••••-•••-••-••---•-•••••••---••••-••-•--•••••••-••-•••....•-------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisiol a Sanitary Code— The undersigned further agrees not to place the system in operatio WX to �ce ha be, issued by the board of,health._. . Sign �1 y ----•---------•-_--- ...� Date l Application Approved By.......... ,e..s �,.,,,_ Date Application Disapproved for the following reasons:-------•---------•--------------------------------------------•-----------------------------------•--•--•---•--- ..••-••••••------••-...•••---•-••-•--•••---•----•••-•---•••-•-••••••_-••--•----•-•------••-•-••----••------•...-•.•••------••-••••••------•-•----•-------•-•......-••--••.............................. Date PermitNo........ -------------•--------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD � OF HEALTH ... .�. 13f................OF.... .i ...5. ...al �..�.............. Trrfifiratr of Tuntpli anrr THIS�ISpTO CERTIFY, That the Individual Sewage Disposal System constructed-vim ) or Repaired ( } by..............i y. =--'-c"t.......... ,E ...... .t�..--•---...------•---- InstaLler ---•--1/i4U----------------� ; c{ ..x<• `�-:�G----------_------------------------ has been installed in accordance with the provisions of `ITIE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....� —..�............... dated_.--------.______________._--___-_----_--__--_- THE ISSUANCE OF THIS CERTIFICATE SHALL NABE CONSTRUED AS A GUARANTEE THAT i HE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... 0-• ---5.•• --•g.5...---•------------ Inspector................. ............................................. _ .THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH jti o. FEE... Disposal Works Tunstrudiun Vrrutit Permission is hereby granted........l2�_&t...... ...---•-•-•--------•--------•--•----------------••--•--...------------..............--•-•--- to Construct or Repair ( ) an Individual S Swage Di osal Syp tern _ •- - -.........� .... as shown on the appli tion fo Di . 6a1 Works Constructio' Pertfl Nq "_. rl_�D ........................ ........................................./J' iioard of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS P�. . .�'8. 9 ... . TOP OF FOUNDATION .` CONCRETE COVER ° CONCRETE COVERS 179177.7777Y ., •'a 4' CAST IRON � r OR SCHEDULE 402 MAX. 12"MAX. 4 SCHEDULE 40 PV.C.(ONLY) � P.V.C. PIPE PIPE- MIN: LEACH° PITCH 1/4"PER.FT. PITCH 1/4 PER.FT PIT PRECAST INVERT a LEACHING ` o EL..7.�:lZ.. INVERT INVERT ° . e•�' PIT OR SEPTIC TANK 7�;7 DIST. 75.36 - ' w EQUIV. EL.... EL...... . >x o INVERT �000 BOX �� Q; �. GAL. INVERT , . a p. o; EL..?�`7(.. , INVERT �0 0: ::�: 3/4��T011/2� EL� ... WASHED p;? �oi � �o• _� � '• �t.�y.00 :.'.' STONE /� -- +—6'DI A. —►I PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM ^%ram- Aze- c..vs�,ritr�t NO SCALE -/ -,,+12� A-p"o �o'/3�Y��•o TD t3E �- �a�•�' .�'�so�i�'77 •4T.D 2�s)c�-v w.ri•1 c��s�v SOIL LOG WITNESSED BY : "4"', ( sNfn�5b ,`�) DATE TIME. . ... . . . . . . � 0�'�.`. c��`'�"^� BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ENGINEER ELEV. . . 71�,P4. . ELEV. !'; . . . WO/Co woCotr.. A11 g Z4" S'as°'z- DESIGN DATA DN�is� Rip S•�o NUMBER OF BEDROOMS e � Fivey 73 Sir c z'784a TOTAL ESTIMATED FLOW . . 3_ c? . . GALLONS/DAY �CuSE _ sE p er, n �r3 BOTTOM LEACHING AREA �.�. '. . . SO.FT. /PIT/iz7 7 G.f?D, �Y STbNE3 „ �6 L SIDE LEACHING AREA . . . .zG.3'.� . . SQ.FT./ PIT1-a7.8c.p.� rea�FiNL /o$ �,7� clo GARBAGE DISPOSAL ..Na"�E. .(50 % AREA INCREASE) S te/ �32r Hsq%.,J> TOTAL LEACHING AREA S 7' $. SQ.FT �-,NE PERCOLATION RATE S. R'� ����. MIN/INCH LEACHING AREA PER PERCOLATION RATE G-97-477 SQ.FT./C pp. .... . .WATER ENCOUNTERED NUMBER OF LEACHING PITS APPROVED . . . . . . . . . BOARD OF HEALTH ���• .�O�S77�i✓� o%/ �� -5/OAS DATE . . . . . . . . . . AGENT OR INSPECTOR `1 o EDVNA _ CD 100 IPF ✓ ✓5% / Cam— �`7� S fl o �� L LAB ` PETITIONER � y � vlo, _ � Y Si T� PL, L sf1 s LOCATION SCALE . . ./. . . . . . . . . DATE .TAW j I.986. PLAN REFERENCE �F?.... . i7 77 o8 �- 4� �- 7 Z07- I I � TNoC h 2- o� 8� D I o y �L EY y CVO. d- �® 9fCIST[�EO ' !