Loading...
HomeMy WebLinkAbout0062 CAP'N LIJAH'S ROAD - Health 62 Cap'n Lijah's Road Centerville A= 192-182 i i I UPC 12534 0.2-153L9 tlmm"m �z No. � t'� 5 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for �Disposai *pstrm Const union vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.G j G J 4 A S Owner's Name,Address,and Tel.No. Assessor's Map/Pazcel if Gt 2— A 4 y' Z 60 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. / Q(J fv�<t Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /4e_c Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt�_, r Signed Date ­Z a Z 1 Application Approved by 5L Date �P Application Disapproved by Date for the following reasons Permit No. Z;� Date Issued w ,zr No. 7 G 1 J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpllcatlon for Mlsposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.6 7t'�j C�h 4/ , jp� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Cp�t t ta 2.f 1 -- 6 a ` ile i T*1 Installer's Name,Address,and Tel.No. Q Designer's Name,Address,and Tel.No. T K,A/7 v i Ct / �1./� Q+t K Type of Building: Dwelling No.of Bedrooms ►)lA ! Lot Size sq.ft. Garbage Grinder.( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets RevisionrDate Title Size of Septic Tank w Out Type of S.A.S.' ft.✓ G i Description of Soil - l Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-'site sewage dispQ al system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ' Compliance has been'issued by this Board of Healtb. Signed Date Application Approved by Application Disapproved by Date" for the following reasons Permit No. 'to a( - 2)--7 Date Issued 4p f i THE COMMONWEALTH OF MASSACHUSETTS Z (It e Oov BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CEERTIFY,that the On-site Sewage Disposal system tConst/ry_cted( ) Repaired( -1)_ Upgraded t Abandoned( )by at (� G_. �" `.rt f has been constructed in accordance with the provisions of Title 5 and the for Disposal S stem/�Co�nstruction Permit No, 702(� 2�;&ted Installer z)i&`w wr` �f 1 -• Designer #bedrooms t r� Approved design flow h j 1 gpd 1 1 The issuance of this permit shall not be construed as a guarantee that the system will function.as designed. Date �--1 Inspector l � !, ,t - -. - - - - ------ -- -- -- - ------------------------------------- No: C,a ( `� �- / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at (.. l� ��•J S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction3 mustt be completed within three years of the date of this permit. /, r Date "( -1 1 Approved by DJ � ^ � 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 62 Cap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville _MA 02632 June 1, 2011 --- every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out / forms on the � ,/► I computer,use 1. Inspector: ll only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road — Company Address Marstons Mills MA 02648 /ems City/Town State Zip Code 508-428-1779 SI 12855 _ Telephone Number License Number LU B. Certification t,,•1 -- 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 cc was performed based on my training and experience in the proper function and maintenance of on site p _-N sewage d sposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of =h Title 5(3F10 CMR 15.000). The system: CD F-- al ® Passes ❑ Conditionally Passes ElFails ❑ Needs Further Evaluation by the Local Approving Authority June 1, 2011 Job# 11-94 _ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. W t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal Sy am•Page/-f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 62 Capin Lijah's Road Property Address Richard Plante Owner Owner's Name information is Centerville MA 02632 June 1, 2011 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was scheduled for pumping following inspection. Leaching pit was empty with no evidence of surcharge B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road — Property Address Richard Plante Owner Owner's Name information is Centerville MA 02632 June 1, 2011 required for -- every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ElN ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road - - Property Address Richard Plante Owner Owner's Name information is Centerville MA 02632 June 1, 2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool- ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow 15ins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road _ Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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. Isms•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'" 62 Cap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 _ 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 62 Cap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is Centerville MA 02632 June 1, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank last pumped 1/15/09 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 62 Capin Lijah's Road _ Property Address Richard Plante _ Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Overrflow pit installed 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 C_ap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, baffles were intact and clear. Tank was Scheduled to be pumped following inspection. Grease Trap (locate on site plan): Depth below grade: feet 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: Date 15ins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Capin Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 111 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ww 62 Capin Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 il Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Liquid level was at bottom of both outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Capin Lijah's Road _ Property Address Richard Plante _ Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Original leaching pit had previously failed, Overflow pit had no standing water at time of inspection with no definite sidewall stains. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road Property Address Richard Plante _ Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 _ _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 l Commonwealth _ a th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road Property Address ----_._----.------__.---- _ — Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 ..—_ every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately . . . . . . . . . . . . . .* ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦/ 1 ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ 12 5 21 37 30 59 New Old Cap'n Lijah's Rd. - Commonw• •� ealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Cap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam.- Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 35 and topo map shows property at el 60 Before filing this Inspection Report, please see Report Completeness Checklist on next page. I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 62 Cap'n Lijah's Road Property Address Richard Plante Owner Owner's Name information is required for Centerville MA 02632 June 1, 2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. FEB,1_3 2.... TH COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphration for Di-nVo3ttl Works Cnon,itrurtion rautit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal Syste�at: ........ ---•---•.......................... •••-•---------•••••--•--••-•••----•-•---•----------•----"-.....-----..._............•........ Locatiot \ddress or t N - y '`-----------------------------------•-- �-CVO Owner 11AddEess "_.•" ---•"-"----•--------•--------------------- a)A..i_-_.SNs ...3-`. ......! �. ...�....•= �Yl- Y�.�11.-'••• Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms____. ----Ex ansion Attic Garba e Grinder 44 Other—Type of Building ---------------------------- No. of persons........................--.. Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity----« allons 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 tank ( ) Percolation Test Results Performed by,.------------------------------------------------------------------------ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__.---"-____---___-_ (3, Test Pit No. 2................minutes per inch Depth of Test Pit-_-___-__._______-_- Depth to ground water........................ a ---------------------------------•------•--------•------•------••------•-•-•-----------..._..••••-•-'--------------••-•--•------•----•-......--.........---- 0 Description of Soil........................................................................................................................................ -----------------...-----_----- U ---•--•----------------•-•--------•-------••---•---••-•--------------•--------------------•--•----------•---------------•-----------•----•------•--•---------•-----•-----•---•-•---•...--•-•-----••---•- W U Nature of Repairs or Alterations—Answer when,applic ble----- .�.�1.___._._�.._. �- �.- -i --�.. ...... !._...._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl" ce has been the board of health. Signed .... . ... ........................... ' Date ApplicationApproved By ......... J�-- --- ------------------------------------------------------------------------------------- ------ _ e-...�i. - Application Disapproved for the following reasons: ............................................................................ ......... ............... ..................................... .................... ...................... ............................... ... . .................... q Date Permit No. ..........' _. /------------------------------ Issued .... ..-... .�`— Date THE COMMONWEALTH OF MASSACHUSETTS )BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for DiuVuuttl Works Cnunitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: Urn -------------------------------------------------- --------------------------------------- ---------------------------------------- -- i- Location-tAddrrss or Lot No. �70l� `Q )� --------�-----S-7......................................----------- ............................................. Gr'�Vl... ........ n_... r— Owner Address W 5C d V\ M `-(-T . 11 lr, � R�� U n k� � 1-��c ,-I .........---•--•------- .......................................... -•-------- -------- ------------- ---- ---• , Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.--.. --------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------- w Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity----[Q9.%allons 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 tank ( ) aPercolation Test Results Performed by.---------_---------------- ............................................ Date...................................... 14 Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----..............--... Li, Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water------------------------ R,4 --------------------------------•-------------------------••....-•--....................................................................................... 0 Description of Soil....................................................................................................................................................................... W U -•----------------------•--------------...•----•-••-----------•------------••-------•----•----•--------------------------•----------•--------------------------------•--•....---...........----•----•--. w UNature of Repairs or Alterations—Answer�when_appli ble.-....1�. - .--.--.-�.----A�- ..1. ���. .� �......_.. -- -- J Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compli)61� nce has been issued-•by the board of health. Signed -- --- ....... Dare A hcation Approved B �--�- -- - --..1.. .-.../�,5 . PP PP y ------- - - Date Application Disapproved for the following reasons: ................................... - - - ----------------------------------------------------- .------ ------------------------------------..............----------------------.......----------- _ Date Permit No. --------�----------------- ---------- Issued ------.�..-..�.`---------------------- Date --------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE LLErttfi ate of (111omplia re THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( l� LUg,................ .C_-- - ---- �. �,_.................................................................................................................................................................................... r Installer at ......C� ........... G-Q. C,.�n.._... . .. -----------------------------------e�` �- 1 ....... - has been installed in accordancewith the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...7_S7.'--- ------------ ... dated ............................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY_.-._, ___✓� DATE - ------J------------ Inspec �...... -.............V ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .No - TOWN OF BARNSTABLE r Diupuual Workii Tunutrurtiun "arAit Permissionis hereby granted------ _ta .. l'z wJ� -----------------------------------•------------ -----------------------------•---.-.--..-.---. to Construct ( ) or Repair (✓) an Individual Sewage Disposal System at No. r V �.�,� (=+ C r _ Via, --�'------------ Street r as shown on the application for Disposal Works Construction Permit No ..:. ......... Dated......------- ----� ---------.--- �-- 'Board of Health DATE-------------------;----------:=------— ------------------------•-• �/ FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION G p�,� �,�\ '� E# VILLAGE M10-f Vi'�ASSESSOR'S MAP&PARCEL ,'llV` .'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) i"r (size) JOCt) � NO.OF BEDROOMS OWNER PERMIT DATE: C ATE: S� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ♦fhf\f♦f♦/♦f♦f♦! f f r f f r f i -. f f f f I f f f f ♦ ♦ ♦ \ \ \ ♦ ' 4 \ \ \ 4 \ \ 4 f f f f f ! f ♦ \ 4 4 4 ♦ 4 h \ 4 \ ♦ \ \ k ♦f♦ ♦ ♦ \�kf♦f♦fhF♦f 5 12 21 Y 37 y� 30 59 v� New f .;xr ' ,. ° ' TOWN OF BARNSTABLE LOCATION ��;� ��� \ �,�G� (° _SEWAGE #c' VILLAGE ASSESSOR'S MAP 6t LOT/ -'jr�, INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY J()OC) (� L Ar (��;` �� �/X Q� e LEACHING FACILITY:(type)9'11k- wt,� � (size) S1'�ar(. NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER c9 , BUILDER OR OWNER , DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: f f�`— VARIANCE GRANTED: Yes No f�► At A -tv 4 io kt,,jQ� -�-c7 Pk, ( t � P 1 �J � v FNSTALLER'S TOWN OFBARNSTABLEION Ca �- ��P�+� L� 1 A 1� SEWAGE # EASSESSOR'S MAP & LOT NAME & PHONE NO. TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS Z-- PRIVATE WELL OR PUBLIC WATER 10W BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No cr' ' 30 44 i S -- CO2MMOINTWEALTH OF irLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS- s . . DEPARTMENT OF ENVIRONMENTAL PROTECTION r ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 ¢ i fQ TRUDY CORE p0 ,OR� �OO Secretary' ARGEO PAUL CELLUCCI �f[,1f�D I STRUHS Governor Co sionFer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM pu 1 i=Ie VI L(-(= PART A CERTIFICATION Pr A eDs�s: ` C AOU L I S A g S R D Name of Owner�c1V Fejes T)-1 }y1L` ��{ �ga Address of Owner: Date of Inspection:-7 /5-00 Name of Inspector:(Please Print) FOw.4 R 0 C. SO VS F/t-L D 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: EDWAVeD C, BCUSf/EC 0 Marring Address: '9V6 NDw;Cr-/ 1"i4 Q_2�5,;3 Telephone Number: 51 9ky 6 3.2 3 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: XPasses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails / —7 Inspector's Signature: l% -✓ Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS f000 6-4LLCIU SEP7/C 779,UK D_Qox 5 W Foal 10W 6AL I-o00 C EACI-/ Pr7' revised 9/2/98 Page Iof11 A 4L. Printed on Recycled Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A T CERTIFICATION(continued) Property Address:lp2 GAPti OJAI S PO owner: F'oPsyrq Date of Inspection:7-15_v0 INSPECTION SUMMARY: Check(O B, C, or D: A. SYSTEM PASSES: XI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 't y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:P CApA) L IJ 45 P-D Owner: Fo2SYT4 Date of Inspection: 7_tS_DO 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 I revised 9/2/98 Page 3orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q Oieiu L IJ19u S 2O, owner: Forsyr�� Date of Inspection: 7_/5_�d D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or_ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1l2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is.below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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 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" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility-with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:�pa C a PN t I3AHS R� owner: FORS-?rH Date of Inspection: 7-6-00 Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health. _ 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. (7W NER (nOVFO OuT I LA.,cF /c /-)G 0 IV _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. XThe site was inspected for signs of breakout. _ All system components, have been located 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 of construction, dimensions,depth of liquid, depth of sludge,depth of scum. Y The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:C,a C OA; t-019 H S R 0 ,Owner: Date of Inspection: ')_t5-00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms (design): 3 Number of bedrooms(actual):_ Total DESIGN flow 330 Number of current residents:_ Garbage grinder(yes oqsp:X Laundry(separate system) (yes ordjM:1V",; If yes,separate inspection required Laundry system inspected (yes or not Seasonal use(yes or®:ll-o Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or 6d): A-,D Last date of occupancy: / wcCi< R�U COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or(!D.AJo If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: /7� O�✓�L E2 Sewage odors detected when arriving at the site:(yes or®) revised 9/2/98 Pagc6orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (:t4p : LOAg5 RD Owner: FOQS-?� Date of Inspection:7_(S-_00 BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:2L)fl'CuS Material of construction:_Xconcrete_metal Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 2 00 1Lx -I u frog���r�"14 Sludge depth: 1-CH S Distance from top of sludge to bottom of outlet tee or baffle: 7"Vc iS Scum thickness: I ftu H Distance from top of scum to top of outlet tee or baffle: f It,CNS Distance from bottom of scum to bottom of outlet tee or baffle:!yf'f"c"3 How dimensions were determined:*7-gf t' 016,45(lRe, 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.) '711n+Y. (S f N 6,00b Cc&;0rttoAi CotUC 2E7r 691=FLE'S i UQui tD V P 'TO 13L'ITT M O F c)u7-LC—r Pr�E GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C + SYSTEM INFORMATION(continued) Property Address: &I C qpk t1AHS (eo Owner: S`fjl Date of Inspection: -7_1S,Oo TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:4 (locate on site plan) Depth of liquid level above outlet invert:Ar l50TM`1 OF 0 VrLL T Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ©n:F ptee 11y o L)E P/PC p L17— N c7 SOLI OS 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 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • r SYSTEM INFORMATION(continued) Property Address:Cij,Z C AF N L IJ 4 HS R O owner: -Fop'sr-q Date of Inspection: ',,I5—00 SOIL ABSORPTION SYSTEM(SAS)-.LC (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: C)hJC IObO GALLON leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs ofhydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) SOIL_ IS DRY L-flCq PiT IS f-IALF FVC.C.- F 3 FEET' OF 4/2010 .,'US10(F -oco (,uot�k(NG Cof%joirt0AJ CESSPOOLS:_ (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) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:L—2, .C.APN t I J,4l-(S jeo owner: F709s,"N Date of Inspection: 7_IS_00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �o revised 9/2/98 Page 10 of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION(continued) Koperty Address:G,2 CAPN C 1JOH5 RO_ Owner: FoasyrH Date of Inspection:.7_ /5 _00 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) G Rov/UO L"'4 tce M 4 V 72WO /7q revised 9/2/98 Page 11of11 6cz 61 f,u&,,on S E P 0 3 REC'D By � y rod-el✓1 �, �� _ YON C f° 1 G y, leap P1 4vi, 00 4 Maw CA 9, 3 j 4 . i ct G1a 5 ��. i �_ Poo O:5 A acv aleuk I`O � � t t �E 4k�,. F, itkoj ►ate j"a ,�q w `I-a r f� fer. Z c��,,-�- vJ ate r e.�ve< ce t,1 to l oox ;� vJ � Pl � Mid =Walls -�-'Okne� �J/ -Z x C'. clx rl wood t eY jj�g y� P .fir TW 3/0 Wan Jaw 5 �,. ,\ —_�� ____•.�__ Pioi)e, boa rd 5 �CQn�71 1411 mod§ I [V' I V { 1 a A T F K � 7 Cf cc 4 _._._... Ia �. f s l f �t r a -oar- o 4vi fj-ora5e.� Pi a � r . 00 € 1-1 110 8�� rooms Vx 2 3 � . LAW (� — b15 '► i /d ye ice I To 5 1 b . rAho fleLvW