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SENDER' S TELEPHONE: t508) 362-3359
SENDER' S FAX- ( 50a L 362-9944 ,
TOTAL NUMBER OF RAGES (INCLUDING COVER SHES's) :
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" for ation vod aiaod in this facsimile io privileged and confidential
inforaa,ation intended only for roviev and use by the individual or entity
nomad above. If the condor of this aaes.se®o in not the intendod recipient,
you are aotifiod that any disblosure, dissemination, distribution or copying
of this communication or interaction contained herein is strictly
prohibited. It you have saaeived this 40SW rnioation in Orro:t, PLeaao
immediately notify us by telephone.
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Town of Barnstable
HAM
b� Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,RS.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Wayne Miller,M.D.
July 17, 2002
Ms. Kathleen Bresette
19 Old Jail Lane
Barnstable, MA
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F ta68 Br® Zs ,ot e,3,Sa �Nec -x _s �s-51K 0 _�
Dear Ms. Bresette,
You are granted permission to install a composting toilet and to continue to utilize
the existing basin for greywater discharge at 268 Browser Cottage, Sandy Neck,
West Barnstable. This permission is granted with the following conditions:
(1) The applicant shall submit to the Public Health Division clearly labeled
floor plans of the existing dwelling.
(2) The dwelling is restricted to the number of bedrooms which currently
exists. No additional bedrooms will be authorized at this property. No
additions or expansions will be allowed at this dwelling in the future.
(3) The applicant shall record a deed restriction at the Barnstable County
Registry of Deeds restricting this property to the existing number of
bedrooms at this property.
(4) The alternative technology toilet system shall be built to NSF-41
standards and installed in strict compliance with the manufacturer's
recommendations and all applicable requirements of 248 CMR 2.14, 2.15,
and 2.16.
(5) The applicant shall ensure that the plumbing components of the
system are installed by a licensed plumber.
(6) The plumber shall notify the State Plumbing Board (phone # 617 727-
9952) as to the location of the system being installed, the name of the
applicant, and the manufacturer's name and model number.
Perkins
This permission is granted because the physical constraints at the site severely
restrict the location of a conventional onsite sewage disposal system. It is the
opinion of this Board that the installation of a composting toilet would meet the
maximum feasible compliance standards contained within the State
Environmental Code, Title V.
h
y y urs,
. Miller, M.D.
n
Perkins
`J7: 34 BARNS-TABLE HEALTH DEPT 5087906304
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s639• Lei'
r�DhtKt�' REC. BY
Town of Barnstable
S CHED. DATE; 7 9 0;k-
Board• of Health
200 Main Street, Hyannis MA 02601
Office: 508.8624644
FAX: 509-790.6304 Susan G.Rask,R.S.
Sur,mer Kaufrnan,M.S.P.H.
Wayne A.Miller,M.D.
VARIANCE REQUEST FORM
LOCATION
Property Address: 268 Bowser Gotta e Sand Neck Barnstable MA
Assessor's Map and Parcel Number: Size of Lot:
Wetlands Within 300 Ft. Yes x Business Name: n/a
No Subdivision Name.
APPLICANT'S NAAIEr, Bresette Phone
Did the owner of the property authorize you to represent him or her?
� No
PROPERTY OWNER'S NAME CONTACT PERSON j Law— on
Name: Jean and M. Kent Fletcher Name: Kathleen Bresette
Address: 15 Park Street Address: 1 ) •Old Jail Lane
Phone: Wakefield, MA Barnstable, MA
one: 508-362-5155
•781-245-0015
VARIANCE FROM REGULATION(List Reg.) REASON FOR V ivrE
(May attach if more space needed)
Tit1P V mpos, ih_ ilit ;n
system
NATURE OF WORD: House Addition ❑C❑❑❑❑ House Renovation ❑ Repair of Failed Septic System ❑
(to be completed by office staff-person receiving variance request application)
Four(4)copies of the completed variance request form
Four(4)copies of engineered plan submitted(e.g.septic system plans)
1� Four(4)copies of labctcd dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
_ Signed leacr stating that the property owner authorized you to represent him/her for this request
y� Applicant understands,tlrat the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
(for Title V and/or local sewage regulation variances only)
4) Full menu submitted(fur grease trap variance requests only)
Variance request application, fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee onlyl,outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems
[only if no expansion to the building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Susan G.Rask,R.S.,Chairman
NOT APPROVED Sumner Kaufman,M.S.P.H.
REASON FOR DISAPPROVAL I
Wayne A.Miller,M.D.
Q:\HEALTH',WP?ILES\VARIREQ.DoC
.....a. _tea. .'. .a .. , .:J �`i _✓..a. .. r.�v_.. � :`a_.� ...._. _. .
This, day of 2002, JEAN G.B. FLETCFIER (
_ ) and M. KENT FLETCFIER (
), of 15 Park Street, Wakefield, MA 01880, hereinafte ailed the LE1-�
N012� ary S�rr�� agree to SELL, and JOHN BRESET11
KATHLEEN BRESETTE ( ( and�,l-1,w
Barnstable, MA 02630, hereinafter called the BUYER or PUR S of ld Jail Lana,
the terms hereinafter set forth, the following described premises: ER' agrree e to BUY, upon
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The land together with the buildings and improvements thereon situated at Sandy Neck
Beach.Point Barnstable, Massachusetts bounded and described as follows:
Southerly by Barnstable Harbor;
Easterly by lands now or formerly occupied by Harrison and by Poland;
Northerly by land now or formerly occupied by Edson or Quessy; and
Westerly by land now or formerly occupied by Bacon and by Rourke.
For title see deed of Jean G.Fletcher, et ux dated April 24, 1994 recorded in Barnstable
Deeds Book 9194 Page 195;._._.._.._
Included in the sale as a part of said premises. are,the buildings, structures, and
improvements now thereon, and the fixtures belonging to the SELLER and used in connection
therewith including, if any, all venetian blinds, window shades, screens, screen doors, storm
windows and doors, awnings, shutters, furnaces, heaters, heating equipment, stoves, ranges, oil
and gas burners and fixtures appurtenant thereto, hot water heaters, plumbing and bathroom
fixtures, electric and other.lighting fixtures, mantels, outside television anternas, fences, gates,
tri;'e8 shrubs l�;nta rn�l ifNn;it4% .•n is:t; ; e+ .�}„« ,1`tl
.p ) `r'- , a •, w.• ccn itio:'1 ,12�ry'.:i} t11�r-t ���� O garbage
r disposers,
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dishwashers, washing machines and dryers.
Said premises are to be conveyed by a good and sufficient uitcIaim deed
d running to the
BUYER, or to the nominee designated by the BUYER by written notice to the SELLER at least
seven(7)days before the deed is to be delivered as herein provided, and said deed shall convey
a good and clear record and marketable title thereto, free from encumbrances, except as
aforesaid, and (a) provisions of existing building and zoning laws; (b) such taxes for the then
current year as are not due and payable on the date of the delivery of such deed;and (c)any liens
for municipal betterments assessed after the date of this agreement.
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The agreed purchase price for said premises is TWO HUNDRED THOUSAND AND
00/100($200,000.00)ofwhich TWENTY THOUSAND AND 00/100 ($20,000,00)DOLLARS
have been paid this date, TWENTY THOUSAND AND 00/100 ($20,000.00)DOLLARS are
to be paid at the time of delivery of the deed by certified, cashier's, treasurer's or bank check and
the balance of ONE HUNDRED SIXTY THOUSAND AND 00/100($160 000.00)DOLLARS
shall be paid by the joint and several note of the BUYER and his nominee, payable as provided
and bearing interest as set forth in a note attached hereto marked "Exhibit A." and hereby made
a part hereof and secured by.a first mortgage on said premises to be conveyed in the usual form
.with restraint on alienation and with statutory conditions and statutory power of sale.
Such deed is to be delivered at 11:00 AM. on the 5a' day of August, 2002, at the
Barnstable Registry ofDeeds, unless otherwise agreed upon in writing. It is agreed that time is
of the essence of th' agreement.
SELLERS shall retain occupancy until Labor Day 2002
BUYERS pay all legal.fees
This agreement is contingent upon the BUYER, at the BUYER'S sole expense, obtaining
a variance from the Barnstable Board of Health for the septic system on the premises. In the
event that such variance is not obtained, then all down payments will be refunded and all
obligations of all parties shall cease.
BUYER acknowledges that SELLER ha3 represented that SELLER has disclosed any and
all information known to SELLER about the actual or potential lead hazards in the property
which is the subject of this Agreement.- The BUYER acknowledges that he or his agents have
been given an opportunity to examine the premises and that any obligations arising under
Massachusetts General Laws, Chapter 111, Section 197, shall be borne by the BUYER in
accordance with the terms thereof.
Full possession of said premises free of all tenants and occupants is to be delivered at the
t1I??v of the del'a;'ei j'Vftl:¢. $?.d} said N18titi8 a to be then (a) in the same condition as they now
are, reasonable use and wear thereof excepted, (b)not in violation of said building and zoning
laws, and (c) in compliance with the provisions of any instrument hereinbefore referred to. The
BUYER shall be entitled to an inspection of said premises prior to the delivery of the deed in
order to determine whether the condition thereof complies with the terms of this clause.
If the SELLER shall be unable to give title or to make conveyance, or to deliver
possession of the promises, all as herein stipulated, or if at the time of the delivery of the deed
the premises do not conform with the provisions hereof, then the SELLER,shall use reasonable
efforts to remove any defects in title, or to deliver possession as provided herein, or to crake the
said promises conform to the provisions hereof, as the case may be, in which event the SELLER
shall give written notice thereof to the BUYER at or before.the time for performance hereunder,
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and thereupon the time for performance hereof shall be extended for a period of thirty.(30)days.
SELLER shall riot be.obligated to'spend more than $2,000.00 under the terms of this clause,
If at the expiration of the extended time the SELLER shall have failed so to remove any
defects in title, deliver possession, or make the premises conform,as the case may be, all as
herein agreed, or if at any time during the period of this agreement or any extension thereo> the
holder of a mortgage on said premises shall refuse to permit the insurance proceeds, if any, to
be used for such purposes, then, at the BUYER'S option, any payments made under this
agreement shall be forthwith refunded and all other obligations of all parties hereto shall cease
and this agreement shall be void without recourse to the parties hereto.
The BUYER shall have the election, at either the original or any extended time for
performance, to accept ouch title es the SELLER can deliver to the.Wd premises iin their then
condition and to pay therefor the purchase price without deduction, in which case the SELLER
shall convey such title, except that in the event of such conveyance in accord with the provisions
of this clause, if the said premises shall have been damaged by fire or casualty insured against,
then the SELLER shall, unless the SELLER has previously restored the premises to their former
condition, either (a) pay over or assign to the BUYER, on. delivery of the deed, all amounts
recovered or recoverable on account of such insurance, less any amounts reasonably expended
by the SELLER for any partial restoration, or(b)if a holder of a mortgage on said premises shall
not permit the insurance proceeds or a part thereof to be used to restore the said premises to
their former condition or to be so paid aver or assigned, give to the BUYER a credit against the
purchase price, on delivery of the deed, equal to said amounts so recovered or recoverable and
retained by the holder of the said mortgage less any amounts reasonably expended by the
SELLER for any partial restoration,
The acceptance of a deed by the BUYER or his nominee as the case may be, shall be
deemed to be a .full performance and discharge of every agreement and obligation herein
contained or expressed, except such as are, by the terms hereof, to be perforined aver the
delivery of said deed.
To enable the SELLER to make conveyance as herein provided, the SELLER may, at the
time of delivery of the deed, use the purchase money or an,, portion thereaftto Blear the'title of
any or all encumbrances or interests, provided that all instruments so procured are recorded
simultaneously with the delivery of the deed or within a'reasonable time thereafter by the
conveyancing attorney in accordance with customary practices.
Until the delivery 'of the deed,the SELLER shall maintain insurance on said premises as
currently insured.
Water use charges and taxes for the then current year shOl.be apportioned
Y pp ned and fuel value � II
shall be adjusted, as of the day of performance of this agreement and the net amount thereof shall
be added to or deducted from, as the case may be, the purchase price payable by the BUYER
at the time of delivery of the deed.
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If the amount of said taxes is not known at the time of the deliveryof the
hall
be apportioned on the basis of the taxes assessed for the Preceding deed' they ent
as soon as the new tax rate and valuation can be ascertained; and,if the tlaxes th a which are two be
apportioned shall thereafter be reduced by abatement, the amount of such abatement, less the
reasonable cost of obtaining the same, shall be apportioned between the parties, provided that
neither party shall be obligated to institute or prosecute proceedings for an abatement unless
herein otherwise agreed.
The BUYER represents and warrants to the SELLER that the.BUYER has not contacted .any real estate broker in connection with this transaction and that the BUYER was not directed
to the SELLER,as a result of any services or facilities of any real estate broker. The BUYER
agrees to indemnify and hold harmless the SELLEP,from and against all claims for brokerage
or commission on account of this transaction by any person who establishes by court action a
right to such a commission arising out of his dealings with the BUYER, provided the BUYER
is given the right, at BUYER'S election, to participate equally with the SELLER in the defense
of any such claim. The SELLER warrants and represents that he has no so-called "exclusive
brokerage" arrangement with any real estate broker. The provisions of this paragraph shall
survive the delivery of the deed.
All deposits made hereunder shall be hold by the SELLER as Escrow Agent,.in escrow,
subject to the terms of this agreement and shall be duly accounted for at the time for performance
of this agreement. Interest shall belong to whomever is entitled to the deposit at the termination
of this agreement.
If the BUYER, shall fail to fulfill the BUYER'S agreements herein, all deposits made
hereunder by the BUYER shall be retained by the SELLER as liquidated damages as his sole
remedy at law and in equity.
If the SELLER or BUYER, executes this agreement in a representative or fiduciary
capacity, only the principal or the estate represented shall be bound, and neither the SELLER or
BUYER so executing, nor any shareholder or beneficiary of any trust, shall be personally liable
for any obligations, express cr implied, hereunder,
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The BUYER,acknowledges that the BUYER has not been influenced to enter into this
transaction nor has he relied upon any warranties or representations not set forth or incorporated
in this agreement or previously made in writing.
The SELLER shall, at the time of the delivery of the deed, deliver a certificate from the
fire department of the city or town in which said premises are located stating that said premises
have been equipped with approved,smoke detectors in conformity with applicable law.
The SELLER shall execute and deliver simultaneously with the delivery of the deed such
documents as may reasonably be required by the BUYER or its attorney or the attorney for any i
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lender financing BUYER'S purchase of the premises, including, without limiting the generality
of the foregoing, certifications or affidavits y
is with respect p t to: apersons
in
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ssion
of the premises; (b)facts or conditions which may give rise to mechanics'orpmaterialme ls(c)the true purchase price of the premises and whet her the SELLER has or intends a loud
the BUYER a portion thereof, and (d) non-foreign status under Section 1445 of the internal
Revenue Code.
All notices required or permitted to be given hereunder shall be in writing and deemed duly
given when(1) mailed by registered or certified,first-class mail, return receipt requested,postage
prepaid (2) han&delivered, (3) sent by facsimile, or (4) sent by overnight delivery service,
addressed:
if to SELLER;to:
with a copy to:
JOHN R, AL(3ER, ESQ.
JOHN R. ALGER, P.C.
5 PARKER ROAD
PO BOX 449
OSTERVILLE, MA 02655
Phone: ; 508-428-8594
Fax: 508-420-3162
if to BUYER TO:
JOHN BRESETTE
KATI-R,EEN BRESETTE
19 OLD JAIL,LANE
BA.RNSTABLE, MA 02630
with a copy to:
PETER J, LEVERONI, ESQ,
45 BRAINTREE HILL OFFCE PART,
BRAINTREE, MA 02184
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Phone: 781-848-9720
Fax: 781-848-9642
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If any errors or omissions are found to have occurred in any calculations or figures used
in the settlement statement signed by the parties(or would have been included if not for any such
error or omission) and notice hereof is given within two months of the date of delivery of the
deed to the party to be charged, then such party agrees to make a
or omission. payment to correct the error
This instrument, executed in quadruplicate, is to be construed as a Massaehueefts contract
is to take effect as a sealed instrument, sets forth the entire contract between the artier is
binding upon and enures to the benefit of the parties hereto and their respective heirs parties,
executors, administrators, successors, and assigns, and may be cancelled,modified or amended
only by a written instrument executed ted by both the SELLER and at' BUYER, two or more
persons are named 'herein as BUYER, their obligations hereunder shall be Joint and several.
BUYER �-,` �. -
BUYER 'Gv yer
SELLER SET,LEk
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$160,000,00 Date:
FOR VALUE RECEIVED, WE,JOHN BRESETTE and KATHLEEN BRESETTE, both
of 19 Old Jail Lane, Barnstable,MA O2630, jointly and severally, Promise to pay to JEAN B,G.
FLETCHER and M. KENT FLETC
HER or order, at 15 Park Street, Wakefield, Massachusetts,
01880, the Sum of ONE HUNDRED SIhTYpOsq A 001100 ($16Q,000,00)
DOLLARS without interest, but with interest at the rate of SEVEN per cent (7%)per annuin on
any balance in the event of default, as follow payable s.
Four (4) payments of$40,000.00 dollars, payable annually on May 30, of each year,
reserving to the Maker the right to prepay this loan in whole or in past at any time without penalty,
Any default of principal or interest obligations as provided herein existing for more-than
thirty(30) days shall make the remaining unpaid balance due and payable immediately, without
notice, at the option of the holder.
The holder at its option may make a late charge equal to three(3%)percent of any interest
and principal payment delinquent for more than fifteen(15) days.
All parties now or hereafter liable for the yr�a .p ent of any of the indebtedness hereby
evidenced agree, by executing or endorsing this note or by entering into or executing any
agreement to pay any indebtedness hereby evidenced, that the owner or holder hereof shall have
the right, without notice to deal in any way at any time with any party or to grant any extension
of time for payment of any of said indebtedness or any other indulgences or forbearances
whatsoever without in any way affecting the liability of any party hereunder. If the note is placed
with an attorney for collection, all parties herein agree to pay all costs of collection including
reasonable attorneys' fees.
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The alienation of title by mortgagor, either by sale or transfer shall cause the balance
remaining unpaid to become due and payable at the option of the holder hereof and the acceptance
of any payment hereunder from the then owner of the equity of redemption shall not constitute a
waiver of this provision and the mortgage shall be due and callable on demand of the holder
hereof.
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This note is secured by a first mortgage of real estate in Barnstable,Barnstable County,.
Massachusetts, to be recorded at the Barnstable County Registry of Deeds.
Executed as a sealed instnunent.
Witness J In Bresette
Witness
Kathleen Bresette
�'►'��45 O.lora� $�t5etfQ
NOTICE TO MAKERS: THIS NOTE IS A CONTRACT FOR A SHORT-TERM
LOAN. THIS 'LOAN IS PAYABLE IN FULL AT MATURITY. YOU MUST REPAY THE
ENTIRE PRINCIPAL BALANCE OF THE LOAN AND UNPAID INTEREST WHEN DUE.
THE LENDERS ARE UNDER NO OBLIGATION TO REFINANCE THE LOAN AT THAT
TIME. YOU WILL,THEREFORE,BE REQUIRED TO MAKE PAYMENT OUT OF OTHER
ASSETS YOU MAY OWN, OR WILL HAVE TO FIND A LENDER WILLING TO LEND
YOU THE MONEY AT PREVAILING MARKET RATES WHICH MAY BE
CONSIDERABLY HIGHER THAN THE INTEREST RATE OF THIS LOAN.
Date June 13, 2002
Mr. and Mrs. Walter Ernst
1550 Nelson Road
Vassalboro, ME 04989
Dear Mr. and'Mrs. Ernst
I am writing to inform ,you of our request for variances from the State Environmental
Code Title V, and from local Board of Health Regulations in regards to our new septic
system which will be installed at 268 Bowser Cottage, Sandy Neck, Barnstable
We are requesting a variance from installation of Title V. septic system
The Board of Health meeting will be held on Tuesday July 9, 2002 , YM at
7:00 p.m., or as soon thereafter as practicable at the Second Floor Conference Room,
New Town Hall, 367 Main Street, Hyannis, MA.
The letter is to serve as an official notification to abuttor(s).
Sincerely yours,
Name peter J. Leveroni, Attorney for Kathleen Bresette, et al
Q:heal Uiiwp tilcs%abbutor
170'd 17O£9O6LBOS ld3a H.L-I`d3H 319V-LSN-dVU SS :LO ZO-ZZ-RvW
Date June 13, 2002
Ms. Dorothy Eide
1222 Ellison Street
Falls Church, VA 22046
Dear Ms. Eide
l'am writing to inform you of our request for variances .from the State Environmental
Code Title V, and from local Board of Health Regulations in regards to our new septic
system which will be installed at 268 Bowser Cottage, Sandy NPr•k, Rnrnetable
We are requesting a variance from installation of Title V septic system
The Board of Health meeting will be held on Tuesday .July 9, 2002 Wft at
7:00 p.m., or as soon thereafter as practicable at the Second Floor Conference Room,
New Town Hall, 367 Main Street, Hyartnis,iNIA.
The letter is to serve as an official notification to abuttor{s}.
Sincerely yours,
Name Peter J. Leveroni, Attorney for Kathleen Bresette,, et al
Q:heal tMwp tiks:abbutor.
tr0'd VOS§06L8OS 1d30 Hl-1V3H 31GV-LSNI:IVG SS :LO- ZO-ZZ-Rvw
Date June 13, 2002
Mr. and Mrs. Ralph Trisko
8005 Overfield Court
Bowie, MD 20715
Dear Mr.and Mrs. Tr i sko
I am vvriting to inform.you of our request for variances from the State Environmental
Code Title V, and from local Board of Health Regulations in regards to our new septic
system which will be installed at 268 Bowser Cottage, Sandy Neck, Barnstabl e
We are requesting a variance from installation of Title V septic system
The Board of Health meeting will be held on Tuesday July 9, 2002 , DDW at
7:00 p.m., or as soon thereafter as practicable at the Second Floor Conference Room,
New Town Hall, 367 Main Street, Hyannis, MA.
The letter is to serve as an official notification to abuttor(s).
Sincerely yours,
Name Peter J. Leveroni, Attorney for Kathleen Bresette,et al
Q:health%wpf Icslabbutar
VO d trOE:906LBOS ld3O H-LIV3H 3' 2VJ-SNbVG SZ=LO ZO-ZZ-xEW
Elite JUnn 13, 200
Mr-and Mrs. Henry E. Blair
P.O. Box 648
Barnstable, MA 02632
Gear Mr. and' Mrs. Blair
I am writing to inform ,you of our request for variances from the State Environmental
Code Title V, and from local Board of Health Regulations in regards to our new septic
system which will be installed at _268 Bowser Cottage, Sandy Neck, Rarnstnhl e
We are requesting a variance from installation of Title V septic system
The Board of Health meeting will be held on Tuesday July 9, 2002 , 1999xat
7:00 p.m., or as soon thereafter as practicable at the Second Floor Conference Room.
New Town Hail, 367 Main Street, Hyannis, MA.
The letter is to serve as an official notification to abuttor(s).
Sincerely yours,
Name Peter J. Leveroni, Attorney for Kathleen Bresette, et al
Q:heal th%wptileslabbutor
tb0'd tPO`r906L80S 1d30 H11b'3H 318V,LSN'dV8 S£=LO ZO-33-xvw
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COMMONWEALTH OF MASSACHUSETTS
tl 1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTIII[ENT OF ENVIRONIIBNTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:d�� ✓O w S e Y- L S
ale ryi�
eH. 1 G 7 r^
Owner s Name° df"
Owner's Address:
Date of Inspection:
Name of Inspector: ( lease print) O/
Company Name: r`EG —
Mailing Address: n
Telephone Number 50
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection..The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems- I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15,000i The system:
S, $ ✓"1 Passes
" Conditionally Passes
,Needs Further Evaluation by the Local Approving Authority
L,- Fails
Inspector's Signature: a Date: /S A!
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 o ner and copies sent to the buyer,if applicable,and the approvingSs�U
authority.
0 ._O OS�" 1 /�? r " raj.%?e"
Notes and Comments G y el �"�j e
****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.
Page 2ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4r wsef� �o�/Ic,
Owner: 1 L-
Date of Inspection: 44p
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found anv information which in Cates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure tcna not evaluated are indicated below.
Comments:
B. System Conditionally Passe .
One or more system c ponents as des ribed in the"Conditional Pass"s ion need to be replaced or
repaired.The system,upon mpletion of the r placement or repair,as approved y the Board of Health,will pass.
Answer yes,no or not e'ternuned(Y,N,ND) • the for the following s tements. If"not determined"please
explain.
The septic is metal and over 20 yea old*or the septic tank vhether metal or not)is structurally
unsound,exMbi substantial infiltration or ex-FIT tion or tank failure i imminent. System will pass inspection if the
existing tank i eplaced with a complying septiq tank as approved by a Board of Health.
*A metal sep c tank will pass inspection if it is cturally sound,n t leaking and if a Certificate of Compliance
indicating t t the tank is less than 20 years old i available.
ND expla•
bservation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruct d 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:
i
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: I &V
Owner: ��?
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions east 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 ealth determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in am ner which will protect public health,safety and the vrronmeni:
— Cesspool or privy is wi 5 feet of a surface water
— Cesspool or privy is wi n 5 feet of a bordering vegetated wetland or a salt arsh
2. System will fail u ess the Boa d of Health(and Public Water S pplier,if any)determines that the
system is functionin in a manner hat protects the public health, fety and environment:
_ The syste has a septic and soil absorption system AS)and the SAS is within 100 feet of a
surface Ovate supply or tribu ,to a surface water supply.
The stem has a septic to k and SAS and the SAS s within a Zone 1 of a public water supply.
system has a septic and SAS and the S is within 50 feet of a private water supply well.
e system has a septic and SAS and c AS is less than 100 feet but 50 feet or more from a
priv to water supply well**. Me od used to termine distance
* This system passes if the well water lysis,performed at a DEP certified laboratory,for coliform
acteria 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:
1
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: &k-S-ter--' Co
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 omponent due to overloaded or clogg AS or cesspool
Discharge or ponding of effluent to the ace of the ground or surface waters ue to an overloaded or
clogged SAS or cesspool
Static liquid level in the distributio x above outlet invert due to an ov oaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less 6" low invert or available vol a is less than%z day flow
Required pumping more than times in the last year NOT due to c gged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,ce pool or is below high groun water elevation.
Any portion of cesspool o privy is wi ' 100 feet of a surfa water supply or tributary to a surface
water supply.
Any portion of a cess of or privy is i ithin a Zone 1 of ublic well.
Any portion of a ces of or privy is i rithin 50 feet of a rivate water supply well.
Any portion of a ce pool or privy is 1 ss than 100 fee but greater than 50 feet from a private water
supply well with o acceptable water limlity analys' . [This system passes if the well water analysis,
performed at a EP certified labor tory,for c fform bacteria and volatile organic compounds
indicates that a well is free from llution fr m that facility and the presence of ammonia
nitrogen an itrate nitrogen is equ I to or 1 ss than 5 ppm,provided that no other failure criteria
are trigge .A copy of the analysis ust attached to this form.]
(Yes/No) The ystem fails.I have etc in t one or more of the above failure criteria exist as
describe in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Healfh determine what will be necessary to correct the failure.
E. Large Syste s:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 610, 1�✓SP�
Owner•
Date of Inspection: _ p�
Check if the following have been done. You must indicate"ves"or"no"as to each of the following-
Yes No
Pumping information was ovided by the owner, occupant,or Board of lth
Were any of the system c ponents pumped out in the previous two eeks
Has the system receiv n anal flows in the previous two week riod
Have large volumes f w er been introduced to the system r Gently or as part of this inspection
_ .Were as built pl s of the system obtained and examined (If they were not available note as N/A)
Was the facili or dwelli g inspected for signs of se age backup
Was the sit spected for signs of break out
Were all stem compone ts,excluding the S , located on site
_ _ Were a septic tank manli es uncovered, ned,and the interior of the tank inspected for the condition
of the battles or es,material of const ction,dimen ons,depth of liquid,depth of sludge and depth of scum
W the facility owner(and cupants' different from owner)provided with information on the proper
maintenance f subsurface sewage dispo I syste s
e 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 Feld(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /JOG✓ e2— Co y�
/ � C
Owner: �� �✓
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#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or.no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):
Water meter readings,if available(last 2 ears usage(gpd))
Sump pump(yes or no):_
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 C 5.20 ): gpd
Basis of design flow(seats/pers ns/s ,etc.):
Grease trap present(yes or no
Industrial waste holding sent es or no):
Non-sanitary waste dischar d to the itle 5 system(yes or no)
Water meter readings,if a 'fable:
Last date of occupancy/u
OTHER(describe):
GENERAL INF RMATION
Pumping Records
Source of info on: ,
Was system pu d as part of the in ction(yes or o):
m
If yes,volue mped: pllo --How was iantity pumped determined?
Reason for p ping:
TYPE OF STEM
_Septic distribution box,soil bsorptio system
Singl cesspool
Ove ow cesspool
Pri
_S ed system(yes or no)(if yes,a previous inspection records,if any)
_ vative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtain 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):
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ��G✓- � /�
// ✓✓ C
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply we I or suction line:
Comments(on condition of joints,v ing,evidence of leakage,etc.):
SEPTIC TANK:_(locate on s' e p )
Depth below grade:
Material of construction:_co crete metal_fiberglass_polyethylene
other(explain)
If tank
t is metal list age:_ s age co armed by a Certificate of Compliance es or no):—(attach a copy of
cerDimensions:
Sludge depth:
Distance from top of slud a to bottom o outlet tee or baffle:
Scum thickness.
Distance from top of sc to top of outle tee or baffle:
Distance from bottom scum to bottom f outlet tee or baffle:
How were dimension determined:
Comments(on pump' g recommendations inlet and outlet tee or. affle condition, structural integrity, liquid levels
as related to outlet i ert,evidence of I e,etc.):
GREASE T _(locate on site plan)
Depth below de:
Material of co struction:_concrete_metal fi glass_polyethylene_other
(explain):
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fr m bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-- PART C
SYSTEM INFORMATION(continued)
Property Address: C¢�./ 13..e
Owner:
Date of Inspection: y Out,
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of constructiom concrete metal fiberglass polyet
_ hylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/da
Alarm present(yes or no):
Alarm level: Alarm in working der es or no):
Date of last pumping:
Comments(condition of alarm and floa switch s,etc.):
DISTRIBUTION BOX: (if resent musl be opened)(loc/osite plan)
Depth of liquid level above outl t invert:
Comments(note if box is level d distributio to outlets equalence of solids carryover,any evidence of
leakage into or out of box,etc
PUMP CHAMBER: (locate on siteUplan)Pumps in working o (yes or no):
Alarms in working or r(yes or no):
Comments(note con 'tion of pump champs and appurtenances,etc.):
J
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM' INFORMATION(continued)
Property Address: �Gv1P�/ C=soi C
/1/C C
Owner: F -v
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits..number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensio
overflow cesspool, number:
innovative/alternative system T /n a of technology:
Comments(note condition of soil,si s of h Wic failure,level of ponding, p soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool ust be pumpe as part of i/velond
te on site plan)
Number and configuration:
Depth—top of liquid to inlet fert:
Depth of solids laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater nilow(yes or no):
Comments(note conditio of soil,signs of hydra is failure, g,condition of vegetation,etc.):
PRIVY: (locate n site plan)
Materials of construc on:
.Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
C Owner:
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.
low—
Page 11 of 11
OFFICIAL INSPEC
TION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: donv-.5�2✓ co/43
Owner: ��
Date of Inspection:_.!�4La,--ZAL
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water f' t
Please indicate(check)all methods use determine the high ground wate elevation:
Obtained from system design pl s o record-If checked,date of esign plan reviewed:
Observed site(abutting prope /obse ation hole within I50 fe of SAS)
Checked with local Board of ealth-e lain:
Checked with local excavat install rs-(attach documenta on)
Accessed USGS database lain:
You must describe how.you stablished the 'gh ground w er elevation:
D f W YII
r�
`n P4Ltu CHURCH: UA, 22046
ni Postage $ t�=v4 U.N. T ! nv
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Certified Fee
Q` Postmark
CO Return Receipt Fee a r Here
r-U (Endorsement Required)
ORestricted Delivery Fee } 4
(Endorsement Required) J(�
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0 Total Postage&Fees $
r3 Recipients Name(Please Print Clearly)(to be completed by m
A -Ms,- DQrothy Eid
O Street A t.No.;or PO Box No.
0 122T Ellison Street
o ------------------- -----------------------------------------------------------------------
` City,State,ZIP+4
Falls Church, VA 22046
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PS Form 3800,February 2000(Reverse) 102595-99-M-2087
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete iterris 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired.' _ ❑Agent
X
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D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑ No
Ms.- Dorothy Eide
1222 Ellison St.
Falls Church, VA
U/V XX�CertifidMail' ❑ Express Mail
2 j ❑ Return Receipt for Merchandise
\i �QO� ❑ is
Mail ❑ C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from` service labe)1]000 0600`!0028 621-2'5016
PS Form 3811,August 2001 Domestic Return Receipt 102595-01-M-2509
War
UNITED STATES POSTAL SE I j F-irstClass Mil
Postage&Fees'Paid
usps
Permit No.-G-10
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TER LEVERONI, ESQUIRE
b4rro NTREE HILL OFFICE PARK
SUITE 200
BRAINTREE,MA 02184
III!it!I ifilu:1 lit uh 111111 nilh!flif I Ifill i! l li!11
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Mr. and Mrs. Ralph_-Trisko_______________________________
o sr$e�t�,�t.Overf eld Ct.
--------------------------------------------------------------------------------
c P+State,
w e, MD 20715
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�:. +s.!ft +a,"',
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IMPORTANT:Save this receipt and present it when making an inquiry..
PS Form 3800,February 2000(Reverse) 102595-99-M-2087
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Sign ure
item 4 if Restricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse ❑Addressee
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■ Attach this card to the back of the mailpiece, �L I
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ir. and Mrs. Ralph Trisko
8005 Over-Held Ct.
Bowie, ri; 20715
3. Service Type
K]Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number ..7OQQ O�r�0.0028. 6212 502.3
(transfer from service label) .� 4� ?Y..� _ -
PS Form 3811;,,August 20011 �; Domestic Return Receipt 102595-01-M-2509
01,
UNITED STATES POSTAL SERVICE First Class Mail
PostAge&Fekes Paid
USPS
Permit No.G-10
I
• Sender: Please print your name, address, and ZIP+4 in this box •
PETER J. LEVERONI ESQUIRE
45 BRAINTREE HILL OFFICE PARK
SUITE 200
BRAINTREE,MA 02184
I
���3 itt??i?E3ciE?4
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1:3 Restricted Delivery Fee l e t•k!�$�tf� 1
1:3 (Endorsement Required)
0 Total Postage&Fees $ 3.94 ' 1 j/ SPC:)
M Recipients Name(Please Print Clearly)(to be completed by mailer)
O �
---Mrx--and-_Mrs_.-_-Wal.t-er---Ernst----------------------------
p Stra t t No.;or PO Box No.
5�0 I C3 �_ Nelson Rd.
CitState,ZIP+4-------------------------------------------------------------- ---------
assalboro, ME 04989
.��
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PS Form 3800,February 2000(Reverse) 102595-99-M-2087
iSECTION
■ Complete items.1,2,and 3.Also complete Si natur
item 4-if Restricted Delivery is desired. ❑_ Agent
■ Print your name and address on the reverse X M Addressee
so that we camreturn the card to you.
P. B. Received by(Printe Name) C. D e of elivery
• Attach this card to`the back of the mailpiece, [ t k� R( 6 �'
or on the front if space permits. "v
D. Is delivery address different from item 1 Yes
1. Article Addressed to: If YES,enter delivery add r ss below: No
Mr. and Mrs. Walter Ernst 3 A
Vassalboro, ME -04989
3. Service Type
LYCertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
i 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from'seniice label) 17000 i0600 100281 6212i 5009 j 1!11 a, q
iPS Form 381,1 August 20011 1 i 1 1 Domestic Return Receipt 102595-01-M609
UNITED STATES POSTAL SERno -
Sender: ® rst�f'�A/lail,
'ems a_ ege&Fee�aV
• Please prini� 'L) e, address, and"ZtP*4-i i o `'
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PETER J. LEVERONI, ESQUIRE
45 BRAINTREE HILL OFFICE PARK
SUITE 200
BRAINTREE,MA 02184
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fll 1.n 5cjy(Endorsement Required) f J
r-3 Restricted Delivery Fee �Xlg Ot
O (Endorsement Required) h/1on
C3
s n_4
O Total Postage&Fees $ `t' SIPS
Recipients Name(Please Print Clearly)(to be completed by
Mr. and Mrs. HenryE. Blair
i p Street,Apt.No.;or PO Box No.
P.O. Box__6.48
o --
Ci ,State,ZIP+4
Barnstable, MA 02632
Certified Mail Provides: t
M A mailing receipt
o A unique identifier for your mailpiece
Io A signature upon delivery
12 A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail.
n Certified Mail is not available for any class of international mail.
n NO INSURANCE'ICOVERAGE IS PROVIDED with Certified Mail. For
valuables,please considergnsured or Registered Mail
0 For an additional fee,a,Re;urn Receipt may be requested to provide proof of
delivery'.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to thg article and add applicable postage to cover the
fee"Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a;USPS postmark on your Certified Mail receipt is
required, /
o For"an additional"'fse, delivery may be restricted to the addressee or
addressee's authorized=agent.Advise the clerk or mark the mailpiece with the
endorsement:Restricted Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.-
PS Form 3800,February 2000(Reverse) 102595-99-M-2087
i SENDER: C009PLETE THIS SECTION CbMPLETE THIS SECTION ON DELIVERY
• Complete items 1,2,and 3.Also complete A.Miure
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we Can return the Card to you. B. Received by(Printed Name) C. gatte elive
■ Attach this card to the back of the mailpiece, G
or on the front if space permits.
Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: . ❑ No
Mr. and Mrs. Henry E. Blair
P.O. Box 648
Barnstable, ILIA 02632 �
3. Service Type
®Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number I
(Transfer from service label); ,I i 7.000, 0600 0028{6212 I;50303 t i i i i i i i
PS Form 381'1,A6gust'2001' Domestic Return Receipt 102595-01-M-2509 1
UNITED STATES POSTAL SERVICES First-Class Mail,---
��� Postage&Fees Paid
LISPS
y „ Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in-this box •
PETER J. LEVERONI, ESQUIRE
45 BRAINTREE HILL OFFICE PARK
SUITE 200
BRAINTREE,MA 02184
fit ' 8
ry'�, jij.....iiI.. h:iEi1lEi�EE1?isiS��I..... 11, IEE1E1Ei`EI —1
Catalog Pg. 72 Page 1 of 3
f
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,yy
Up News Contact Info The Business
Links
Sun-Mar Composting Toilels
EXCEL N.Y.
904-001$8799 '
Catalog Index The EXCEL N.E. was first introduced in 1981 and has proven itself capable of handling 5-
gc' 7 people in weekend and vacation use or 2-3 in residential use. Indeed
the EXCEL N.E.long ago o established itself as the standard toilet for
those living"off the grid". It consists of a large volume insulated bio-
IJ� ,,,,those
a finishing drawer and an evaporating chamber. The EXCEL k
N.E. has a 4"vent(supplied with the unit)which is mounted at the top 5
rear. This vent acts like the chimney on a woodstove to induce draft,
Y� l and draw air in through the intake holes, and in from around the toilet Y 7"
Vl�Qg seat. To get good air movement,the vent should be erected as close to
vertical as possible. fi
If the EXCEL N.E. is going to be used.heavily, or
Did V V J residentially, or is to be installed in a place which is
u particularly subject to a downdraft, a 12 volt fan should be installed in the vent
fVF�o stack. The fan draws 1.4 watts and can be used with a solar panel and/or 12 volt
*� �A'�battery. A 1" drain is fitted to the rear of the unit, and this should be connected to
an approved drain pit or similar facility.
This toilet works well if it is used as it is designed to be used. The toilet should
be at indoor temperature to allow liquids to evaporate up the 4" vent pipe, and to
allow the bacteria to be active and thus digest the waste. We used one every day
at New England Solar Electric when we were without a septic system in our
previous location. Our composting toilet was cold for most of the winter,but
functioned well anyway. We added an efficient DC fan to help evaporate the
liquid during the cold months.
v Sun-Mars are made in Canada and shipped freight collect from Buffalo. You
pay the trucking when it arrives. Allow 2-3 weeks. Freight charges to the
northeast are usually in the $50-$60 range.
Vent Fan for Sun-Mar Toilets
http://www.newenglandsolar.com/catalog_pages/catalog76.htm 3/3/02
f .
Catalog Pg. 72 Page 2 of 3
904-005 12 or 24 Volt Fan$46
Used to increase capacity and evaporation on EXCEL or CENTREX N.E.
Recommended for residential or heavy use. The fan comes mounted in a piece of
Sun-Mar 4" duct pipe and mounts directly on top of the toilet.
CENTREX N.E.
.w s<
904-002 Centrix 1000 N.E.$879
Continuous Use:N/A
Weekend&Vacation Use 4/6
H 27.5",D 26.25",W 35.5"
904-009 Centrix 2000 N.E.$949
Continuous Use: 3/5
Weekend&Vacation Use 6/8
H 27.5",D 26.5",W 48.75"
904-010 Centrix 3000 N.E.$1419
Continuous Use: 5/7
Weekend&Vacation Use 8/10
H 31.5",D 26.5",W 69.5
The CENTREX N.E. is a non-electric central composting toilet system. This
type of system is designed for those who prefer a flush toilet in the bathroom,
with the composting unit outside or in the basement. This central composting unit
is normally within 20'of the toilet and is connected via a 3" plumbing pipe.
Installation requires hooking up the water supply to the low flush toilet,
connecting the 3" waste piping to the composting unit, and assembling the vent
stack(included with the unit).
The CENTREX N.E. was first produced in 1993 and has the same capacity bio-
drum as the EXCEL. It is a low profile unit making installations under buildings
where height is important much easier. Although distances of over 20'between
the low flush toilet and composting bio-drum are not normally recommended,
central units have been successfully installed up to 40' away from the toilet.
Recommended capacity for the CENTREX N.E. is 6-8 people for weekend or
vacation use and 3-4 people for residential or continuous use.
Sun-Mar Low Flush Toilets
904-003 SEALAND 2010$199A
904-004 SEALAND 510 Plus$229
The Sealand 910 and Sealand 510 are 1-2 pint super low flush
toilets for use with the Centrex N.E. central
composting toilet system described above. The
� a<<
510 is a regular size toilet, while the Sealand 910
is slightly smaller for use in tight locations. They are made of
fine china for superior quality, hygiene and cleanability. Sealand
http://www.newenglandsolar.com/catalog_pages/catalog76.htm 3/3/02
Catalog Pg. 72 Page 3 of 3
r toilets come complete with seat assembly,pedestal cover, floor
{, seal and mounting bolt package.
Composting Aids
904-006 Compost Quick 16 oz.$13
Combination toilet bowl cleaner
and compost accelerator.
904-007 Microbe Mix 16 oz.$17
Dried aerobic microbes
and enzymes to initiate composting.
904-008 Compost Sure 7 gal bag$15
Mixture coarse peat moss
and hemp bulking material.
Be sure to check out Sun-Mar's Home Composter on Page 93
T
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http://www.newenglandsolar.com/catalog_pages/catalog76.htm 3/3/02
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11
I
June , 2002
We, M. Kent Fletcher and Jean G, B. F7 etcher,hereby authorize Peter J. Leveroni,
Esq.to file for a variance with the Barnstable Board of Health in connection with a Title
S application for our property at Sandy Neck
Very truly yours,
M. Kent. (etcher
I
can G.B. Fletcher
i
i
I
Town of Barnstable 1'# X? L
Department of Health,Safety,and Environmental Services
a�Ti Public Health Division Date 3 1 Y `7
Q, 367 Main Street,Hyannis MA 02601
BARNgrABIZ
lE010.t�`� Date Scheduled 3 — l 8- Time Fee Pd. 6'e�;Ir,)
Soil Suitability Assessment for Sewage Disposal s
I Performed By: —10'1 CU A,—A»��WN �E G 1N.� Witnessed By: JC1117,I -bomyI/)G
LOCATION & GENERAL INFORMATION
Location Address Owner's Name CA1,16
Address 2�j`� PTLw4u:5 ^V,
Assessor's Map/Parcel: t g 3 14 Engineer's Name �W N
NEW CONSTRUCTION REPAIR Telephone# 2 Lk 12-k k
Land Use f jk2XtjGC Slopes(%) 0 10 Surface Stones
Distances from: Open Water Body ft Possible Wet Areal n ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
M 183 �V
57.E VT
ovs�'ro�5►, L,eL�
MI.
t
Parent material(geologic) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Grn�tndwz:ter T`117o►t.�.Y IJr'I,.�L;,t`1 G .�i M"_j
DETERMINATION.FOR SEASONAL HIGH WATER'TABLE
Method Used:
Depth Observed standing in obs.hole: Nit VATM FAM-T) in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date time 130
Observation
I tole# Time at 9"
Depth of Perc .. Time at 6"
Start Pre-soak Time @ 0 ! d 0 Time(9"-6")
u q �
End Pre-soak �` \ °JA� 1 1 ' 00
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back--�
Copy: Applicant
i
DEEP OBSERVATION HOLE LOG Hole #
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.%Gravel)
0- 1 O o(tGANsL
W - t 20 G I Mt;pF A 2 4 5/1.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color I Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
oGravel)
DEEP OBSERVATION HOLE LOG.` ' Hole'#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Hilo °o Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) '" (Munsell) Mottling (Structure;Stones,Boulderes.
n istency.° rae
Flood RuraRce Rate MAp;
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_ Yes C, 0• 1'7
Within 100 year flood boundary No_ Yes To NC- A 3 4z-:., I rr P N Zrj00 D 1 o o%Nb
Depth of Naturals Occurring Pervious Material T 1°1VZ.
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
'area proposed for the soil absorption system? �
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on A10 V r (date)1 have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017.
Signature --7r--�°� `�"' Date `1� �'
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
A a DEPARTMENT OF ENVIRONMENTAL PROTECTION
5� ya - FAIL PECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
Property Address: C� •��' d0 C� MAY 3 12002
�
Owner's Name: kre�,,4- TOWN OF BARNSTABLE
Owner's Address: :� / c , f�. HEALTH DEPT.
Date of Inspection: �t
Name of Inspector: (please print)
Company Name: _ L,4/ i c
Mailing Address:
Telephone Number L64.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
jePasses
Conditionally Passes
Nwds Further Evaluation by the Local Approving Authority
(/ Fails I,
Inspector's Signature: Date: sk '
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 approvingSb
authority. cc" `/ .`
Notes and Comments
Ro
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
i � 1
w rE lRbECIDI
Page 2 of 11
Y
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner•
Date of Inspection: pj,
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found anv information which in 'cafes that anv of the'failure criteria described in 310 Ckk
15.303 or in 310 CMR 15.304 exist. Any failure feria not evaluated are indicated below.
Comments: '
B. System Conditionally Passe . F
One or more system c portents as des ribed in the"Conditional Pass"s ion need to be replaced or
repaired. The system, upon mpletion of the r placement or repair,as approved y the Board of Health,will pass.
Answer yes,no or not eternuned(Y.N,ND)'in the for the followings tements. If"not determined"please
explain.
The septic is metal and over 20 yea old*or the septic tank hether metal or not)is structumliv
unsound exhibi substantial infiltration or exfi tion or tank failure i imminent. System will pass inspection if the
existing tank i ,;replaced with a complying septi tank as approved by a Board of Health.
*A metal sep c tank will pass inspection if it is cturally sound,n t leaking and if a Certificate of Compliance
indicating t , t 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:
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: d C „ -c C� a
/ Ive e
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions ceist 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.
I. System will pass unless Board of ealth determines in accordance with 310.CMR 15.303(1)(b)that the
system is not functioning in a m• ner which will
protect public health,safety and the vironment:
_ Cesspool or privy is wi 5 feet of a surface water
Cesspool or privy is«i n 5 feet of a bordering vegetated wetland or a.salt arsh
2. System will fail u ess the Boa d of Health(and Public Water S pplier,if any determines that the
system is functionin in a manner hat protects the public health, ety and environment:
_ The syste has a septic and soil absorption system AS)and the SAS is within 100 feet of a
surface wate supply or tribu to a surface water supply
The stem has a septic and SAS and the SAS s within a Zone 1 of a public water supply.
system has a septic and SAS and the S is within 50 feet of a private water supply well.
_ e system has a septic and SAS and a SAS is less than 100 feet but 50 feet.or more from a
pn to water supply well**.Me od used to termine distance
* This system passes if the well water lysis,performed at a DEP certified laboratory,for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 1 I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: CC- Ci e,— e
A e C �%
Owner: IV
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 omponent due to overloaded or clogg SAS or cesspool
Discharge or ponding of effluent to the ace of the ground or surface waters ue to an overloaded or
clogged SAS or cesspool
Static liquid level in the distributio x above outlet invert due to an ov oaded or clogged SAS or
cesspool
Liquid depth in cesspool is less 6" low invert or available vol a is less than''/:day flow
Required pumping more than times in a last year NOT due to c gged or.obstructed pipe(s).Number
of times pumped
Any portion of the SAS,ce pool or is below high groin water elevation
Any portion of cesspool o privy is wi ' 100 feet of a surfs water supply or tributary to a surface
water supply.
Any portion of a cess of or privy is ithin a Zone I of ublic well.
Any portion of a ces of or privy is i rithin 50 feet of a rivate water supply well.
Any portion of a ce pool or privy is 1 ss than 100 fee but greater than 50 feet from a private water
supply well with o acceptable water piality analys* . [This system passes if the well water analysis,
performed at a EP certified labor tory,for c fform bacteria and volatile organic compounds
indicates that a well is free from p Ilution f m that facility and the presence of ammonia
nitrogen an itrate nitrogen is equ to or 1 ss than 5 ppm,provided that no other failure criteria
are trigge .A copy of the analysis ust attached to this form.]
(Yes/No) The ystem fails. I have determin t one or more of the above failure criteria exist as
describe in 3l0 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health determine what will be necessary to correct the failure.
E. Large Svste s:
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)
ves no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered
"yes' in Section D above the large system has failed The owner or operator of any large system considered a
significant threat under.Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of I 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �li'�✓SP
Owner: F le.7e tt"✓
Date of Inspection:
Check if the following have been done. You must indicate"ves"or"no"as to each of the following-
Yes No
Pumping information was ovided by the owner, occupant. or Board of Ith
Were any of the system c ponents pumped out in the previous two eeks
Has the system receiv n rmal flows in the previous two week riod
Have large volumes f w er been introduced to the system r cendv or as part of this inspection
Were as built pl s of the system obtained and eramin (If they were not available note as N/A)
Was the facili or dwellii ig inspected for signs of se age back up
Was the sit spected for igns of break out
Were all stem compone ts,excluding the S ,located on site
Were a septic tank manh es uncovered, ned.and the interior of the tank inspected for the condition
of the baffles or es,material of const ction, dimcn ons,depth of liquid depth of sludge and depth of scum
W the facility owner(and cupants different from owner)provided with information on the proper
maintenance f subsurface sewage dispo l syste s
ie 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 any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) 1310 CNM 15.302(3)(b)�
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /JOG1' 5 '1—
// C
Owner: l�
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#of bedrooms):.
Number of current residents:
Does residence have a garbage grinder(yes or no):_
Is laundry on a separate sewage system(ye or no):_ [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):—
Water meter readings,if available(last 2 ears usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL r
Type of establishment:
Design flow(based on 310 C 5.20 ): gpd
Basis of design flow(seats/pers ns/s etc.):
Grease trap present(yes or no ._
Industrial waste holding went es or no):—
Non-sanitary waste dischar d to the itle 5 system(yes or no _
Water meter readings,if a ilable:
Last date of occupancy/u
OTHER(describe):
GENERAL INF RMATION
Pumping Records
Source of info on:
Was system p d as part of the in ction(yes or o):
If yes, volume mped: _gallon --How was uantity pumped determined?
Reason for p ping:
TYPE OF STEM
—Septic distribution box,soil bsorptio system
_Singl cesspool '
Ove ow cesspool
Pri
—S ed system(yes or no)(if yes,a previous inspection records,if any)
_ vative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtain 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):—
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: 4V
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply we 1 or suction line:
Comments(on condition of joAing,evidence of leakage,etc.):
SEPTIC TANK:_(locate Depth below grade:
Material of construction: cmetal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ s age co armed by a Certificate of Compliance
certificate) es or no):_(attach a copy of
Dimensions:
Sludge depth:
Distance from top of slud a to bottom o outlet tee or baffle:
Scum thickness:
Distance from top of s to top of outle tee or baffle:
Distance from bottom scum to bottom f outlet tee or baffle:
How were dimension determined:
Comments(on pump* g recommendations inlet and outlet tee or affle condition, structural integrity, liquid levels .
as related to outlet i ert,evidence of leaT.etc.):
GREASE T _(locate on site plan)
Depth below de:_
Material of co struction:_concrete_metal fi glass_polyethylene_other
(explain):
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fr m bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: "
Comments(on pumping recommendations,inlet and outlet tee or baffle condition. structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: del
Owner:
Date of Inspection:
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/da
Alarm present(yes or no):
Alarm level: Alarm in working der es or no):
Date of last pumping:
Comments(condition of alarm and floa switch s,etc.):
DISTRIBUTION BOX: (if. sent mus be opened)(locate o site plan)
Depth of liquid level above outl t invert:
Comments(note if box is level d distribution to outlets equal, y evidence of solids carryover,any evidence of
leakage into or out of box,etcp
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,con 'o f pumps and appurtenances,etc.):
IPage9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: F/,&-� -
Date of Inspection: +— �lvi •
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number: `
leaching trenches,number,length:
leaching fields,number,dimensio
overflow cesspool, number:
innovative/alternative system T /n e of technology:
Comments(note condition of soil,si s of h ulic failure,level of ponding, p soil,condition of vegetation.
etc.):
CESSPOOLS: (cesspool ust be pumpe as part of inspection)( to on site plan)
Number and configuration:
Depth—top of liquid to inlet fert:
Depth of solids laver:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater nflow(yes or no):
Comments(note conditio of soil,signs of hydra is failure,I veI of ponding,condition of vegetation,etc.):
PRIVY: (locate n site plan)
Materials of construc on:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: eocll:�-e-,--- cc /`c�
ctvl
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.
Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM//INFORMATION(continued)
Property Address: 17�
2✓ Ca/45
Tec
Owner:
Date of Inspection: dy
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water f t
Please indicate(check)all methods determine the high ground wate elevation:
Obtained from system design p s o record-If checked,date o sign plan reviewed:
Observed site(abutting prope /obse ation hole within 150 f of SAS)
Checked with local Board of ealth-e lain:
Checked with local excavat I install rs-(attach documenta on)
Accessed USGS database lain:
You must describe how you stablished the igh ground w er elevation:
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