HomeMy WebLinkAbout0097 CAP'N JAC'S ROAD - Health 97 Cap'n Jac's Road
A=193-073-TOO
Centerville
S M E A D
No.53LOR
UPC 12543
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No.._.......go Fxs............5V.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH 8
1...........OF...... �..�.�r .( 3. �C.. 1 .............. ............
ApplirFa#ion for Rapaii al Works Tonstrnrtinn ramit
Application is hereby made for a�Psermit to Construct ( _100'or Repair ( ) an Individual Sewage Disposal
Sy tern at:
..... . .
'T
ocati9sr Address S or Lot No.
.......................... ............... �' ..ik ! P.,,,.-----•-•---------------------------•--
oner Address
.................................
Installer Address
QType of Building Size Lot...,_gr.1. 2.. Sq. feet
U Dwelling—No. of Bedrooms...........: .. _Expansion Attic ,OVA Garbage Grinder (0,6
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aOther fixtures .......................................................................................................................................................
W Design Flow.......t1.0...........................gallons per person per day. Total daily flow.........3a a....................gallons.
WSeptic Tank—Liquid capacityl - l-.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter____--__-___-__..___ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing t ( )
W Percolation Test Results Performed by........ -.-----� _,c................. Date...... .........
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----____-_-_-__---_-__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------•-------•--•----•--•--------------------•-••-••••••-•...............--------------------•---••----••-•._.............
O Description of Soil.._7.' 4
` ( IfXL... __.... �4_ ?-1. ..............
U
W
---------------------------------------------------------------------------------------•-----------------------------------------------------........................................................
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 provisions of TI'L a 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of ealth. t
Signed--- 1 '-44A...' .. ........ .. ..i���....----•----- ••-- ....................
�
Q Dat
Application Approved By - - - -_--------------•- C Z".
Date
Application Disapproved for the following reasons:-----•-------------------------•------------------------------------------------------------------•-••••-------.
..............•---••..........-•-••-•-------•--------•-•-•-•-•--------•--------•-•-....•------------•--•----------•-----•-----•-•-----••--------------•--- ---•-----•--..----•---•--•-•----•--------
v � • -.Date
Permit No. _. ...�?.. .............. Issued............�. ..... ---
Date
l
No......... .. ..1 FEig.............................
THE COMMONWEALTH OF MASSACHUSETTS
t
BOARD OF HEALTH
.........:3 ..044.-----------OF.......--..�..�..f ..�a.......----.Q.LE................................
Appliration for Uiipniial Workii Cfnnstrnrnnn thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy tem at
..._..s-s
ocat' -Address3
.R_c`� ._s..._.. .._. .rA.R_ __�?�........................... Rsrc .........................................
ner A dr s
.... .................................. A A R Iv 5T_ � c,
,-�
Installer
Address U Type of Building Size Lot..�_ !,._..yy
-t.��.Sq. feet
I—. Dwelling—No. of Bedrooms.......... .............................Expansion Attic X/0) Garbage Grinder 40)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .........................-----•---•---------------------••------------•
W Design Flow....._1.(o............................gallons per person per day. Total daily flow___........3. _!q .gallons.
W Septic Tank—Liquid capacityl Q00.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing t ( ) ff
aPercolation Test Results Performed by--------Q A.)! Date_._.~1�_ ._.....................
Test Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--__----___-_-__---•----
Grq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --••••......•... --••-•------•-••-••-•••.•• •----•----.....•--•--••••--......••......--••----•-•-•.........................................................
O Description of Soil•. ........ ---�......J�U• •j01 .-•-•••................................................
txj -•-----•------------------- �_�_l. ...... = ? All -
-- ----------------_--- --------------------------------------------...---------------------•-----------------------•-----------------------------------••------------------••-•-••--•-••••••._.......
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 provisions of TITLE:, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of I ealth.
Signed------� •-•. --- -...-•-- ......... - --- --------•-------------••-- ----------------�•e-•-••-•- •-
Application Approved By............................ _ �i
X .........................................
Date
Application Disapproved for the following reasons---------------•--------------------------------------------.................................................
•-•-•-••-•---••••••••-••••----•^..._......Date ......•••...
Permit No._.__._..?. — 4� �- d
-------------•----•------------------- Issued.-----..__.."/..� ---�-•----�---!-----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ...........OF........... .a: .. .L ............................
Trdifiratr of Tn mptianrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (__'�or Repaired ( )
by........�J.E. .' '� ........ -'
l `Installer. _
at ... /SOT `......----- f P .....
p = . IQ.,_ f l l
has been installed in accordance with the provisions of TI he State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__. �'__ �
. --............. dated - 3
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UE® AS A GUARANTEE THAT THE
SYSTEM WALL FUNCTION SATISFACTORY.
DATE..........L....� ...�� .............
Inspector............... ......••... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t�.. f c� ...........................................OF..................................................................................... t
No.... ................. FEE..:....................
Uispwial Worku 041nitrnrtinn rrniit
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or..Repair ( ) an Individual Sewage Disposal System
at No.
Street
as shown on the application for Disposal Works Construction Permit Noo...................... Dated..........................................
A
---------------------------------•-•----------------------------------------------------•••......--.•-_•-
DATE. Board of Health
FOR1 1255 A. M. SULKIN, INC., BOSTON
�I • II►.�GLL- FAMILY - :3 BCURnoM
uo GACZBA6E 6e,NDE-9Z
' pAILY FLOW z 110 x 3 = 73oG.Pv
:5EPT%G -rA*jK = 330x150% =A99&.P. o ISM �3
u 5 E- ►0 0 o
OISPoSAL PIT L1.�i1r �Iv00 GAL. IZ&.� �1,18'1. '�I
S 1 DG vdA�L AtzGA - 1 JO S.F. co
l Ne
150 s-r- Z•5 �- 375 G.Po
gOTtOM AREA: ., lac S.F, 14- Y-/3/ -
50 S.F X (• O TH. Ex
p
-TOTA>-. DESIGN s ,a25 G,Pp. Iz�.z Aac�► W,L --- /246
-ToTA%- DA I LS( FLOY4 = - 33o G.Po
P¢�
PG2COL-ATION RATE VIM 2MIPJ OP-LESS
PACHARD
SAXTER 29
14o.24048
STS
SUS :,;:'. .' eke
T6�T F�=I28 TO
3zs> .»-
�
f �* I'z -i��y�c' 7��� d 1�• sfFr
„ loco INV.
/ LL ty 15T. INS• .,G&L. �Z3
�7JPfit7(i IOuo INS. BoX Z'3�C. -rAnIK
4 G&%-. 1
LCACu
PIT INV. INV.
WITH ktj•7-
IL3 b
WASNGD
j Fug 6TuNEr
a-"t 1.7
G62TIPIG0 PLOT PI-AN
i' PRor~1t_�
Wo� SCALE
o LVATY?L P i`.A►.� REF r= GE
E� NER=o W GOMPU� !S fin!TN"C NEE Slot--L%W ESN
�T Iz
AND S6'TBAV< p_rmQ0I9-1:MENT•> or- -rv,E
i� -ToWN of T34(2-41rA131:6 AND IS qo ' R 1-o+`L AiMt Swl 1fiti4 II �Z��83
LOGAT�E����,W� IT1111�1 T46 1: 000 PLAIW
DAT E�.1:_= �j Cam _
BA.KTEtze IJ`{E INC.
iZEG 1 SZ irP-Er 1AN D s v ZV EYoeS
Tu15 PLAN 15 t�io*T BN5c D oa AN osTECZv1LLE • MASS•
IN5•T•RuM�t�IT yUV-Vey � -TNF l.�1=FSE'T�S Suoul�
No-T 131= u5ED'Tb Ve-TE.FCMl►-lrm I..cT t_ Ir.lE.-j APPI-lCP.►`_jT' `, A ,�, (L. �v1.. ,Tla
�t►.�G t..C— F A n1l 1�t_�(`.,. - ;3 B�U R o o M .Z , . � ,,
WO GAtzgAGE- (,wntDE2
D O P to hIL�( F�ow .: 11U x 3c 7,,3 G.
JEPTIG TASK = 33Ox15C>% - 49 j;6
u5E- %00o GAL.
D15Po5At_ P1"r y5E t000 GAL-. lag. l�, 182 I -Q 1
5 t VSWAL.t_
t5o 5.1= X 2.5 - 3'15 G.Pq , izg:d r:_ FNa. `
�J S.F K I. O
-7oTA I- L7 F.51 GN
-TcTA%_ •DA I L-.' F1..Otrf - 330 6.P0. -----,_
�1 •1
PE2C0L-AT►c)N RATE : l"ir 1 2MIN 01_1_I~55
II .,
PETER ' (°3
I eac1AD S U L i;
'I �AzT€R r1o. 29733 �� N
No.24048
Iw �,
N/ir: F^ TOP F N U= 13I
""'-� 4-I-►-��- rG- i17
amply 1000 INV.
ViST. INV. 00.1- 17. 0
,
�jt�7/7G7!(i DU�C SEPT�G 3 8
I000 INV. IZ'3 L . -rAWK
I.z
L_ca�u
PIT INV. INY.
'/IG4I !lWAS416D
ua 6TaNE
C. QTIr-I ca.A P1-oT PLAID
PRUFI L r= LoGA'Tlow
I(3 I4 Wo SGALE 5c'p'LE JIL t'ot� �ATrc
�', No �A P 1--A N 9-r= EN G>r
AT T H E IJd?A-T"14P► SNo wN
I: ►�EREO T•1 GOMF L_ 5 WITO-T HS .S I o6.1-1W t= �' f2
A►.ID SETe)AGK 26QV12�M�N'1"> oF -f41�
l ToWN of 73 -4yrAS46 ANC 1S 1�PJt" FUW 1012.. Slim% '�vm1TIA (117_5183
>_oc_ATET� W1TN1tJ TNE GLOdD Pt,AL1.1
BA-ATEcze Wye: INC.
REG 1.5'T>G26•V'1.AN D S u MY EYoeS
Ttd15 Pt_�►.1 1 5 NoT E3n5r=n ob AN os-mavILLS- • MA615
IW'5TP.UMENT SU2Vey E_ -TVAG_ 0 .SETS SuouL3>
No-t [3F U560TCY DETe?_P\INS t_.oT -INE`j aPPLICA►�'T" 1 AM7 V_' �vv I4
ISIQ(-LL- FAN111-Y.; - BEUP00PA 2
Wo •GAQBAGI= 6v-'h1DE2
DAILY PLOW z IIU X 3 -- 73oG.Pt?
5EPT1G TPJK = 330x15o% 495;6.PQ
U5E•- I000
c�15Po5Al_ PIT v5E I000 COAL. I�&.� ��,'182 t' ' ?e"' o' sit
L,
BOTTOM
` :: < h
�j14-
C 5.P. X I, p 5 O G.P o TH: \�2.
-To'rA,- DESIGN = 421' G.Po. Iz1.z i. izg
-TOTAL DA I L�( FLDW 3�f0 G,PD,
PE2GoLwrIc)q RATE 1''IN ZMIN oP--LE=55
I• Q(o-'ZI
I
r k
PETERPACHIARD
A.
SULLI
INTER Nc). 29 ,-3
t ,,a�?fin `!1 f• P¢V
BTS
T6,�,T W7-. !3y A'77,e-zg c-' I OPFWO= i3I
�A-fs'w T� F�=
4•IOL1= dr-I"1-8� rr!,- �'L.� � �i\1"�S'�F a,�`Y
l OAIU ,� 1000 INV.
D t ST. INJ GAL
p0X . c,EP7�G 1�3'&
{000 INY, IZ'3,L . TANK
4- Gay.. 123
LEACu
PIT INV. INV.
WIT14 1Z�,,Z (Z3rei.
1'/3/h-1
WASN6D
Hug 6TvN6
it
GERTIPtGA pLoT PLAN
PRUFIL�
Ct`�treL"/I Liz
11� I4 NO `SCALE SCALE ���= (oc� SATE 9-(0-a4
A �3-Z7 $�
I �o trU ETLE►� GE
I GE {ZT1FY 'THAT -TNTFwjr>AT701 5N0WN
NERE0IJ GOMPL\ !S WITN Z!-I6 S 1 V 5:-UW E I J
(2:
A Q D 5 I^T E�GK 2.6 Q V 1 tz>r M t✓N'1'� O F -C µ E- L-dl
i 7a w N or- 73 4"1ST-A►3�S Awv 1 S }��(' `(�C 1� ;YL J AW% (�+M 1,TU 11 Iz5/83
LOCNXED WITNIW TN6 V1-000 PLAIN
D AT 1r CJ Cx ^'`_
BAXTE2e PJ`(E INC.
REG 1 SZ>c2r.U't-AN -5 u V.v EY�eS
'Tu15 Pl.n►.I 1 I�crT �as�n n►d AN d:5'rC- -VILLE- • MA6s-
IN5TRUMEW-r SveVey ir-Tl-IE �?1=FSE'T5 6WOUL3>
NoT i�F USEDTd C�ETE�1�I►.t� �..oT -INI-.' RPPL.ICA►JT ,��.tM h �' �''�^ #TI+4
� .
L 0 CA IT— J 'GG l�T j Ac#-S S E W �M I T NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
/A6
e U i l D E R OR OWNER
S t T4
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
t
C � e
�7� ��
� �'`ry
�.
,�,,
�_
8 V
COMM0\AVEALTH OF MASSACHL'SETTS
EXECUTIVE OFFICE OF E?*VIRO\MF-'\TAL AFFAIR °D AUG 1 3
1997
DEPARTMENT OF ENVIRONMENTAL PROTECT 100 Mew Diu
, i
a
l� ONE WINTER STREET. BOSTON. NIA 02108 617-292-5;00
A
W'ILLIAM F.WELD TRUDY COXT
Gov ano SeCretan
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions:
PART A
e��tN CERTIFICATION
�ry 1 )
Property Address: ��"� c�G�'S o�_ (P_Jxu� lj L4P-_Address of Owner:
Date of Inspection: p s owl c (If different)
Name of Inspector: �i.�c.
I am a DEP approved system in pector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: `r �t.�r ItA . i` La. c
Mailing Address: P^ aC ! 'a -%,CL /7i9-S/-71Fe-0- /IA e)
Telephone Number: 4a---`- /4- 2 Q
CERTIFICATION STATEMENT
I certi� that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and comolete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ !Needs Further Evaluation By the Local Approving Authonn
Fads
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority, within thirty (30) days of completing this
inspection,. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
e] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revlsod 04/25/97) Page 1 of 10
DEP on the Worid Wide wet httZ)./twwwrnagnet.st2te.ma.us/aep
"A' . I •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continue )
s n .� .
Property A d d r e s s �— �c��>L c
Owne'ri . v
,Dyed of Inspection:r
p B] SYSTEM,CONDITIONALLY PASSES (continued!
T—'�-I t,
A
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
- a — CERTIFICATION (continued)
Property Address: el-,-t�!
0wner. /Z-� �,i2 f�c"c.G —�-
Date of Inspection:
DJ SYSTEM FAILS: 7
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool..
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov;.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe!sl.
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply- or tributary to a surface water supply.
Any portion of a cesspool or pray is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety, and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: /Z =�L., �•
Date of Inspection:
Check if the `.towing have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
X None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
AAs built plans have been obtained and exarmned. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil .Absorption System, have been looted on the site.
•. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material or construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility o,,.•ner (and occupants, if differen: from owners were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
—t-- SYSTEM/ INFORMATION /
Property Address:
Owner: __S t/2KOtUSv.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 530 tt.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:-IL2,
Garbage g,,:der (yes or no):�_�
Laundry corrected to system (yes or no): ry�
Seasonal use tyes or no): N)v �
Water meter readings, if available (last two (2) year usage (gpd): tjz . Nibs c liwaz .
Sump Pump Ives or noi: Pp
Last date of occupancy: y.�l
COMMERCI.ALIINDUSTRIAL•
Type of establishment.
Design flow: galions/dav
Grease trap present: Ives or no'_
Industrial \/Vaste Holding Tank present. eyes or no)_
Non-sanitary waste discharged to the Titie 3 system: ryes or no:_
k, ater meter readings. if available
Last Pate or o cupanC'\
OTHER: (Describe
Last date of occuoanc�,.
GENERAL INFORMATION
PUMPING RECORDS and source of.information:
�s�:yV� dV�w t•.��turkC9 , �o+�.w c 14T 3�" ►uv ,Q.� �Lo vv+.y1Y ru d ���'Q.nl C t
System pumped as part of inspection: (yes or no)--&W,
If yes, volume pumped: ISOO gallons
Reason for pumping 1k�Ptl�\lti�IC
TYPE OF SYSTEM
_ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pri\,y
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)A!d
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ess: y7
Owner:
Date of Inspection
BUILDING SEWER: 0-1
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other (explain)
Distance from private water supply well or suction li-e
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plane
Depth below grade:tZ'
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed bv Certificate of Compliance (Ye&!No:
Dimensions: 1O00!1*l
Sludge depth: 8%"
1
Distance from top of sludge to bottom of outlet tee or baffle: 3 L
Scum thickness:_
Distance from top of scum to top of outlet tee or baffie a
Distance from bottom of scum to bottom of outlet tee or barhe:- (W
How dimensions Here determined: #kRWUJ
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.). o"i"-t PV�'t — AAI'�t'.1TIFtN[� �%� ���ukcA
r t ,At lbaLa��
GREASE TRAP: �y
(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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: y -
�Owner:/Z ��Date of Inspection:
TIGHT OR HOLDING TANK: f7aank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacm: gallons
Design flow: gallons/da�
Alarm level Alarm in working order_ Yes; _ No
Date of previous pumping
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
DISTRIBUTION BOX: CS
(locate on site plan;
Depth of liquid level above outlet invert:
Comments:
(note if level and distributio . is equal, ev'den of solids carryover, evidence of leakage into or out of box, etc.)
^D^13o x,w QQ,GD
r
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.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: de-_77t�a_ c cA.2 s r
Date of Inspection:
SOIL ABSORPTION SYSTEM SAS):
(locate on site plan, if possible; excavation not required, but'may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: bRL
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions.
overflow cesspool, number:
Alternative system:
Name of Technologv:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetat n, c.) ,
o�
CESSPOOLS: �o
(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 (cesspool must be pumped as part of inspection)
Comment-:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: AN
(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.)
Ar
(revised 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: r� L/�c��—
Owner: 9-
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
z
pt.�. 56
k2— 5 ci
2'A
q(.6 L)i
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
/
Property Address: C G� J�c S /c!cl C 4--- vt
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA maps
Check pumping records
Check local excavators, installers
Use ISCS Dara
Describe in vour o%+•n words how you established the High Groundwater Elevation. Must be completed;
US15 �oav (�-4ydtcol�• �N��•��v.v� d, P}. bqZ�
(revised 04/25/97) Page 10 of 10
a
a ATLANTIC ENVIRONMENTAL
P.O. BOX 2384
� i MASHPEE,MA 02649
Attn: Commonwealth of Massachusetts Date: 06/21/96
Town of Barnstable
Board of Health
367 Main Street
Barnstable, MA 02630 _
x �
s, �`"�,
From : Mr Michael DeDecko
Po Box 2384 `pcElya &f
Mashpee MA 02630 g � J U N 2 5 g`
agM
4+
Dear Board of Health Official;
I certify that I have personnally inspected the sewage disposal systems at the following
address : 97 Capt Jac's Road. Centerville, Ma.
The informations reported are true, accurate and complete as of the time of the
inspection.
If you have any questions regarding this inspection, please contact me at this number:
(508)477-14-20. Thank you.
jS' erely,
Michael DeDecko
phone 508 477-1420
r l
Commonwealth of Massachusetts
Executive of Environmental Affairs
DES
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
C A PA)
Property Address: 97 Capt J ac's Rd. Centerville, M a.
Address of Owner: Barbara-& Paul D. Ottino
(if different)
Date of Inspection: 06/20/96
Name of Inspector: Michael DeDecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 - M ashpee Ma 02649. -Tel : (508) 4771420
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is true, accurate and complete as of the time of
inspection . The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. The system
- -- Passes
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
,Inspector ' s S i9 natuie. ` t..` Date: 06/21196
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. I f 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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 97 Capt J ac's R oad. Centerville.M a.
0 wners : Paul & Barbara O ttino
Date of Inspection : 06/21196
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
-X-- I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are
indicated below
B)SYSTEM CONDITIONALLY PASSES:
---- One or more system components need to be replaced or repaired. The system, upon
completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated", explain why not.
---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or
exfiltration , or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
H ealth.
---- Sewage backup or breakout or high static water level observed in the distribution
box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven
distribution box. The system will pass inspection if (with approval of the Board of
Health).
----- broken pipe(s) are replaced
----- obstruction is removed
---- distribution box is levelled or replaced
---- The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
----- broken pipe(s)are replaced
----- obstruction is removed
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : 97 Capk J ac's R oad. Centerville, M a.
O wner : Paul & B arbara O ttino.
Date of Inspection: 06/20/96
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering,vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
---- The system has a septic tank and soil absorption system and is within 100 feet to a
surface water supply or tributary to a surface water supply.
---- The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply well.
---- The system has a septic tank and soil absorption system and is within 50 feet
of a private water supply well
---- The system has a septic tank and soil absorption system and is less than 100
feet but 50 feet or more from a private water supply well, unless a well water analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 97 Capt J ac's Road. Centerville,M a
Owner: Paul &Barbara Ottino
Date of Inspection : 06/20/96
D) SYSTEM FAILS (continued)
-- 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 1/2 day flow.
--- Required pumping more than 4 times in the last year NO T due to clogged
or obstructed pipe(s).
number of times pumped
--- Any portion of the Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary to a surface water supply.
---Any portion of a cesspool or privy is within a Zone I 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 ana-
lysis. If the well has been analyzed to be acceptable, attach copy of well
water analysis for coliform bacteria, volatile organic compounds, ammonia
nitrogen and nitrate nitrogen.
/1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 97 Capt J ac's Road. Centerville, M a.
Owner: Paul &Barbara O ttino
Date of Inspection : 06/20/96
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above
The design flow of system is 10,000 gpd or greater Large System and the system
is a significant threat to public health and safety and the environment because
one or more of the following conditions exist :
--- 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 I I of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00.
Please, consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 97 Capt J ac's R oad. Centerville, M a.
Owner: Paul &Barbara O ttino.
Date of Inspection: 06/20/96
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receivingnormal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up.
--x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components, excluding the Soil Absorption System,have been
located on the site.
---x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees, material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
---x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 97 Capt J ac's Road. Centerville, M a.
Owner: Paul &Barbara Ottino
Date of Inspection: 06/20/96
RESIDENTIAL:
Design flow : gallons
Number of bedrooms : 6 z,
Number of current residents: o?-
Garbage grinder(yes or no) : rye
Laundry connected to system(yes or no): u��s
Seasonal use (yes or no): r�c�
Water meter readings, if available: N
Last date of occupancy:
COMMERCIALIINDUSTRIAL:
Type of establishment:
Design flow : gallons/day
Grease trap present: (yes or no)
Industrial waste holding tank present(yes or no) :
Non-sanitary waste discharged to the Title 5 system (yes or no) :
Water meter readings, if available :
Last date of occupancy :
Other: (Describe) ............................................................................................................
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
....................................
System pumped as part of inspection(yes or no):....0.0........
if yes, volume pumped: .................... gallons
Reasonfor pumping:............................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 97 Capt J ac's R oad. Centerville, M a.
Owner: Paul&Barbara Ottino.
Date of inspection: 06/20/96
i
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)
--- Other (explain)...........................................................................................
APPROXIMATE AGE of all components, date installed (if known) and source of information
...I�W.ao ................................................................................................
................................
Sewage odors detected when arriving at the site: [yes or no)..............
SEPTIC TANK . .� 5......
(locate on site plan)
Depth below grade: ...k-Z .
Material of construction: ...X.. concrete ......... metal ........ FRP ........ other (explain)
...............................................................................................................................................
Dimensions:
Sludge depth :...V.`.......
Distance from top of sludge to bottom of outlet tee or baffle:....... ................
Scum thickness :.....k"............
Distance from top of scum to top of outlet tee or baffle: .............\-d.....................
Distance from bottom of scum to bottom of outlet tee or baffle :......�.s:`.............
Comments :
(recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc. .........,............
wA.. ........?`.?........t...
��':,�:�....��..U?.GY-.f�AN�?�L.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 97 Capt J ac s Road. Centerville,M a.
Owner: Paul & Barbara Ottino.
Date of inspection: 06/20/96
GREASE TRAP : .....0(.�$.....
(locate on site plan)
Depth below grade:
Material of construction: ........concrete.........metal........FR P........other(explain)....
.............................................................................................................................
Dimensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
Comments:
(Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:....!N .
(locate on site plan)
Depth below grade:.:—..........
Material of construction:........concrete...... metal.........FR P..........other (explain)..........
................................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallonslday
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
................................................................................................................................................
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 97 Capt J ac's Road. Centerville M a.
Owner: Paul& Barbara Oktino
Date of inspection: 06/20/96
r DISTRIBUTION BOX:..'A:�5
(locate on site plan)
Depth of liquid level above outlet invert:...&c,�A4. A r ' kk
Comment:
(note if level and distribution equal evidence of solids carryover, evidence of leakage into
or out of box, et\c. �- Pork.. .��� \,o •c,�.. ��'c�? -` ,an.. .. ..tom
. �...................., -h)
................................................................................................................................................
PUMP CHAMBER:.... `�...
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):...g4a......
(locate on site plan, if possible, excavation not required,but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
................................................................................................................................................
................................................................................................................................................
Type:
leaching pits, number: ...L.`.4: ::X
leaching chambers,number:........
leaching galleries, number:...........
leaching trenches,number ,length:......................
leaching fields, number, dimensions:...................
overflow cesspool,number:..........
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)...�. �R�- v^..�:�.. s��.� -�Q.P... 1 ... �.�r �.►r , Sri rJ.C(... .Nc:..S.� �ls
WIC , Ow"-c2J F �S1 .vr. �30�.--a So�`,�-e !1 �11 Z.�oz. 7
9'4�..(r\�.)
V-?\ \ WC7 \UAC .c� CT.
.wo
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: 97 Capt J ac's Road. Centerville M a.
Owner: Paul & Barbara O ttino
Date of inspection: 06/20/96
CESSPOOLS:......N�.
(locate on site plan)
Number and configuration: .........
Depth-top of liquid to inlet invert: ...........................
nvert: ...........................
Depth of solids layer: .................
Depth of scum layer: ...............
Dimensions of cesspool: ......................
Materials of construction: .....................
Indicator of ground water: .................... _
'inflow (cesspool must be pumped as part of inspection)
.................................................................................................
.................................................................................................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
................................................................................................................................................
PRIVY : N
...............
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) .
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : 97 Capt J ac's R oad. Centerville, M a.
Owner: Paul &Barbara Ottino.
Date of inspection: 06/20/96
SKETCH OF SEWAGE DISPOSAL SYST
EM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
q% CSQT
1 z
Z 2-
3 d `�` rJ�
tA
DEPTH TO GROUNDWATER:
Depth to groundwater: }.3O.Jeet
Method of determination or approximative:
4.....C.V-A a�?� c ..u?� � �� ... ..':a ................................................
........................ ....................................................................................................................