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HomeMy WebLinkAbout0076 CAPTAIN BELLAMY LANE - Health 76 CAPTAIN Br:L Centerville A = 230 — 185 UPC 12534 No.2_ 153LOR HASTINGS.MN No'. (0- THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH OF_7���A_p............................................... Avvftratiou for %Vasal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ....4-4 4 AF............................................................... Location-Address or Lot No. ............i?_] . ..........4:a ........ ............................. --- ---- aAQ.. ... Owner Address - -,1,.k;=—.......................................................... .......................... ........................5f4, Installer Address U Type of Building Size Lot.i?YiP_q.3-------Sq. feet Dwelling—No. of Bedrooms..........3..............................Expansion Attic Qv4 Garbage Grinder 4 P4 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria 04 Other fixtures ..................................................................................................................................................... Design Flow..........�55...........................gallons per person per day. Total daily flow._._-&:% ............................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length________________ Width_____._.__.___._ Diameter________________ Depth____.__.___..._. Disposal Trench—No_ .................... Width____.___.__.__.___._ Total Length_____.__________._._ Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.____.__._.._..__.__ Depth below inlet______._.___________ Total leaching area..................sq. ft. Z Other Distribution box (� Dosing tank ( ) Percolation Test Results Performed by---7—E"-tiia� ....T_�_.Nxij....................... Date__511C-z1as................ �.l Test Pit No. ...minutes per inch Depth of Test Pit.....1.-7........ Depth to ground water__&,1QN.�......... Lro Test Pit No. 2................minutes per inch Depth of Test Pit._____.___________.. Depth to ground .water______......____._.____. P4 .............................................................................................................................................................. 0 Description of Soil.......Q>.j:_.2...................tv ............................I............................................................ ....................................... ......N.0 U . .............................................................. W ................................................................. ................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................. ................................................................................................................................I...................................................................... 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 th rd of health. Signed. &Z....................... e-_-,X'4165- ................... • Date Application Approved By......... ........ .............................................. ...... Date Application Disapproved for the following reasons:............................................................................................................... ......................................................................................................................................................................................................... Date Permit No.......25_:5i..Gjaa1.................... Issued....................................................... Date -------------- Fss.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. 1�r---------------.....OF...SAP..P-A .4.=, ---------------------------------------------- ApplirFation for Disposal Works C oustratrtion Prrutit Application is hereby made for a Permit to Construct ( I�or Repair ( } an Individual Sewage Disposal System at:.. .5 7 'l ..w7.':�16` c:.td*r�!_.._ ..:5 :�t: _:-s ? ,a,;, ....... .......... ......... ---- ------ Location-Address or Lot No. .......... •�•- 1 .....!::-=k�.��- ------------•---------. C" y 2.. F -j+ = -tea' - �!•a;v 44de:.0 4:1w r• r.. j�Owner Address ►W-a !vlH:.`Ss. Zt' � S S^es�.1-- -----------•-•------------ -----------•---------- �'�•t�*�.......................................................... Installer Address UType of Building Size Lot_2`_ffaf 3........Sq. feet Dwelling—No. of Bedrooms___......_5..............................Expansion Attic (,v,) Garbage Grinder Wj aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures -----------•... -•-••--•---•••. - W Design Flow.........ra`,2 i----------------------------gallons per person per day. Total daily flow____ ..............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (fl Dosing tank ( ) Percolation Test Results Performed by--- ;;,aj,, �: _._.r.,.,. ---••-_---_-----.-- Date...Vi� u:a_______________. Test Pit No. 1..-v_-_ .._.minutes per inch Depth of .Test Pit.....J.Z......... Depth to ground water.A,,,,Q ,t. --__,__. (� Test Pit No. 2................minutes per inch Depth of Test Pit--------------------- Depth to ground water--_______-_.-__----__,_. O Description of Soil------ " ......-• M s csai ---------------- --------------•------------------------ •---------------------------- V ...."l. 1 1"?-• `E � -:� � ..9.4� ; -/ ^.1 ,-'sl&l -------------•--•--------•----------•--------..-------------- ............•-•••-... .... .. W -----••---••-------•--------------------------------•-••-•••-•--•---•-•••--••--.._........-----•••--- ......................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---.........................................-.......................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 oard of health Signed ...;- ............................. Date Application Approved By. ....................................... b Application Disapproved for the following reasons:--•-----•-•---••--•---------------•------•----------•--•------------------- ...............•--•----------•••••-•--••-•-------•---•••-••--.................••--------..............:....•--•-------•---•-------••-----•---•-••-•-------------•-•-------•------•........••------------- Date PermitNo._E= = = CLO 1---------------� - --------. Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .!..s ?wi,4.......................OF.. ! r11. ?SLo e::.......................................... %rrtifiralr of ( ompliFaatrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (A or Repaired ( ) by-•-•--------•-----_•---tAkN �: - -----•-•-----------•-•- f Installer at........ .� - ._ Ar:':: ------ ....................................... has been installed in accordance with the provisions of TIT LF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._. :_c..... dated__________ _____________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A���Qtie►14TEE THAT THE SYSTEM WILL F NC ION SATISFACTORY. - Inspector.........:........DATE................g-.j _• ------........----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . s �l re1!..................OF.... !??yl rt — `. N > L a>cr �� ..................... FEE. A 3 .,`_ Disposal Works Tlonstrartiolt rrudt Permission is hereby granted.......Ah¢ ... ,�� �t ,.`s............................................................................. to Construct (Vel or\Repair ( ) an Individual Sewage Disposal System atNo...... � ............ ...... .4�_ f iE ................................ Street as shown on the application for Disposal Works Construction Perrr=�Nc ............. Dated.......................................... -Boar d----of-- --- ---------------------•-----------•--------._ �,,Y z � �i+,'• H eal=th DATE............. FORM 1255 A. M. SULKIN, INC., BOSTON - Y ALBERT y�� - tM4RSE 6 A s No.^IUD�l J o '�C,c1✓l5 p �. Or �- C5 0(/ICJ. � \ < 13 13 ; 0 7" 4 zi TE. .Rss v ice►G—b L c'�T ✓Z,' 'c pf C_T'f0Al I F Ste-c�:'I�,f,�: 7Ua/ /3/ �+ ' � -• w ` !; OF �,q 3s= r BtRT' ✓� v {; ELDR� ts0. 19367 LEGEND EXISTING,, 9:POT ELEVATION 0,�0 CERTIFIED PLOT PLAN EXIs'1'1NG CONTOUR --- 0 --� 1MI:SHEO SPOT ELEVATION �`v T /4 APT. � /"M y ��(✓�x1f.1M111"ED CONTOUR 0 CC�1/TEic1-"-/4 Z E mx Nflrl'B The location of .any existing undergtound sewerage, I oil 11s., or other utilities shown on this plan ,is approx- � tat�te only as determined from records and/or verbal �+ A I S BIAS.L information: The contractor is' responsible for the R ✓�s G G B.S� iI "veri `cation of the existing locations in the field. $GALES / _` 4' DATE 6 1: DGE ENGINEER/NG Ca 'NOCLIENT. i CERTIFY. THAT THE PROPOSEQ k — BUILDING SHOWN ON THIS PLAN ERiSTERE REGISTERED J08 N0. f '' .CLVIL LAND CONFORMS TO THE . ZONING LAWS E 0 ER LR QR.BY1 �� ' - OF BARNSTABLE , MA39. r ., 3. P" F T12: MAIN STREET. ' CH. BY, MYANNISt' MASS. SHEET OF Z E REG. LAND SURVEYOR -r _ 1, ..•" t - r ¢,:- .. '3 :�.r-- '�.::>•o.- ! - .,'..�'"rc x$Y..t$s`'^' ,•. : r.,:•.+e s 1.:i..� ?. ,;r z i� S �.. � SFY, e.n . �. :�#.,. ..,C - 1TL:� •R..is 1„?" .'ti S°h3.,n. , .�'�y>`..�,^7' �-v� .: � � f'••iS` �'!�'.V;Y- �� . .. n.Y• M....'(jW n. :Y' t, u•V.. .x ' w✓- a eT. } Mcr,; .�.. ..# -..'.7 .,i .ry .. .. :_ s .. t. r,o ;,,v.R.,.w ,• : .: x � _ _;•H. .. 3'. ;:" !c...- ,.....,k'��c`..4, '�� '•u�� -.�..+. ��� ..r ;t�r,v:- � ..r,. ,. .''�,�$.... �.a.: ,. ,,""i.. a �. <: ;A '-;.v +.d.,,) . 4! to}+ ,"h^„'•� ,.... w,,,. a;- ?'7:'e/ � .rw ,R 39}.u. ,�,T..a'.'.,�.�."'�,"Yi ,�r� y� ,;. *+£.^.yt �"{�"',.�-„' x� -��*s£�"�'�-��•e'^�..„'«-,�}.ar..+?a+,'�Y.`r.�'"��o,�.'��^s s�*..sa,+r` � ::, �M.a�...?-''-, ...ad��u. ' ".h:�':2" .•n ...a-7w,. �y - �., r1, tr.� .d.i: �,�,, �r., ,-swa �3 �'-�. � c•a � ti -�- ..�:a i• PT/ .� /F. EJ7'NGR E S E,� C TANK •'1't Sr GiT':'..'4. {STY. MIN .-r�"1.!•,. �:kF�'. l., ti•J". .y _ �.. .M Y, � . 20. `+•�,� _�- LE/�ci� xG •'PST A4/tE'`"lrJORE, TNAJVoELDlV y ;•, i'S- ..F.._ y.. _. `,-.� ,:Ct:....Z-n '� :,R�' ..K:,,`- �m' K,'t.}`#'�`"'�4Yr.} :y. •d -�•4 ,. _ '.�I, f Y . .;. �,,.>•,: �, + .,:, ;.>. ,�r- r.� w• �,, n:,� ��„_; :, ,_ :. ,:- r$ -.z ,.rR/4DEi r4. 24 �! M'F''7`.ER CO%ytR.Er7"E COVER ► KE'' _ r!�.I�v. ,, ro r ^r.:i � �,"'n i 'T: '� w•::, M;•;' '(*.!•.. r 'w7•�,.s''r`.:', J �+'. •'i_ , r 3 SJ�1�lLE'$F'BRDU6N ' TO GRA:OrE .AN .EXTRA • 4'PYC.PIPE CO/VGRCTE i �J! EAV y C/1 ST%RON''CO✓ER S.f%i9 L L 8E [/.SFO f `t :S� GOKERS M N. CN Z>RlV4-WAY �F d1t.�DE GO.V.ER GL'EAN'�SANo ,A — BA Cx;0=14 L - 4 = SCNEOVu•40 � 2�LAYFR b 6/1L. o •. o: •�. . ... . . •• • d • o • WASHED 570/YE %'Flit >• . SEPTIC TANK 'r . . • , . : , • •a.D 1, 1 �EFFEClI✓Gr � *'• s. . , 3�4 - � I2�-. a• DGPTN • • 1 • •. WASXEO STONE 41p' E 7,9 x /.a -. 78 - i s. it . • � .'• • P .�•7 REG14ST SEE.F?4G P fr �. . • • • . • •.1 � . .o P174OR Eq111V. . t vzgr EL EY.4TIONS PIT n a c,T-y '.5-4s ems►c Ie>A Y s E�- ' SS S s 6 fT. PIAM.' INY.ERT.AT aLIILD/NG FT 0 FTn O/AM. cc SEE rA6LL.�4Tl alv� INLET .SEPTIC 7.4NK Ss.-3 FT 09I74ET SEPTIC 7"ANK ES,/ PT. INLET DISTR/8!?/ON BOX 54.9 F'j SECTION C%�' GROUND 1 TfR T/tALE OtITLETD/STRIf3IIT/ON BOX 54f.7 P7 INLET LEACRINre oJ7- 54.5 fT. . SEWAGE O/SP05A L..SYSTEM T�I6ULATlDN .L EACH!/YG JO/T - 3 OIMENS/ON /1 G DES/6X CR/TERIA D/MENS/oN NllINdER OP BEDROOMS 3 D/MENS/ON C_ FT. /N• c�•Ra44s.Fo15,005 J-uw/r N�.�E , SOIL'LOG:_ SD/L TEST TCTitL.EST/ f1.o/'v 3 3 d '49A1-1,0AY SOI L TEST Aft SO/1- 7.FS7'**,2 .'. NUMQER OF'LEACMINT• P/TS / • . �FLEY. 5 G'5- �'EL1�Y. ,DATE OF-SO/L TEST SIONA ACAiING PER PIT �$ SQ fT. O- z ' RESULTS IV/TNESSED dOT'TOM161CN/NG PER P/T 2Sr &ACOLAWOW RArAr 0I GZ�SS 'MlAIIINCH, is i•OTAL LZ4CN/IYG -AREA 2-b h SO. ,F7-. svfs .o� J OICCOLATJON, DATE.�2 Tfr.i9 ^�MI�1l�1NCH. iQESE/CI�EZ&ACNIN6AREA ' - /Z su rzTsT H Ups O, I Lp7-..14 APT- L Q� AKE H t 'wa RLBERT ROBERTLa� Gk' ��✓�� L-e _ r' A :. B. 0 MORSE 10 ELBRED 3E "o. 0951�o No 19367EJIAG/JI/�R//��111►G: MAIN ?., .NQGROtIND �iTER,,E_ .NCOL/NTEREP. t•L/ENT.tG1P�C-�/6k��� ?!�T��:( j .• OUND ,LViATER AT;ELEY per. T JOB /la3 E� �i�Elr aM1M•,M1�'r;:ab5'+-nU'nefA^n`.n!A*r+Tmyx� ..e�.y.'^.'_EI+a^.emery*� «.•lLnn.a..-^na+n+.mw•Y'!`•*sarnw.:,.,a.v:,,c...,we.';..w•w,+wew�•rA'•nr+«wFrtnw,4r+^..•w.+c+cenawM•+YtMwi�.�nxeseem.m•s=r.+-�-..+�a+•tvw, m....mw.art,.r:w..rM,w-'+�Yil.+•rr�.'._•.,r*n+ ,'.•.•n,....t .�••,rt-.w.«w....+..s::.«...v.r«dn..w.-......-uwc ..n-s�e!^'•,.^�'�^.. k 2, 30 - #©usc ,d 76 LQCATION SEWAGE PERMIT NO. VILLAGE M N INSTA LLER'S NAME i ADDRESS - �- Vk, co1� lk5 Vyl nvS 5 4d\/,5 Volt(S e U I L D E R OR OWNER S-c e DA T E P E R M I T I S S U E D '71 �/ ,s' DAT E COMPLIANCE ISSUED /ilg5 �a-� � l�( to�� � N c0 M 5�-�e t Nam• _� ® � 1= t Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of ► E P Environmental Protection William F.Weld Trudy Coxe Gowmor seCf1"ry Arpeo Paul Celluccl David B.Struhs LL Gowmor Commes*W SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 12 PART A CERTIFICATION Property Address ¢ � Address of Owner Date of Inspection: /`2 /- -- `rt (If differento�y Name of Inspector. & Iry Company Name,Address �and Telephone Number. e r � / y � !`9Z 9✓ CP � 0 2- CERTIFICATION STATEMENT/ !� I certify that I have personally inspected the sewage disposal system at this address and that the informati o. is- ' accurate and complete as of the time of inspection. The inspection was performed based on my training and experiences=u► e,p r� ction and maintenance of on-site sewage disposal systems. The system: ,, PasseS _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails inspector's Signature: ✓���L� ,Date The System Inspector shall mit 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: 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. 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 determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",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 ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 0210E a FAX(617)SW1049 a Telephone(617)292-UN iAJ Printed.Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: B)SYSTEM CONDITI NALLY PASSES (continued) Sew `backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(&)are replaced obstruction is removed distribution box is levelled or replaced The system req ' pumping more than four times a year due to broken or obetru pipe(s). The system will pass inspection if(with ap royal of the Boat of Health): broken pipe(s)are replaced obstruction is removed C1 FURTHER EVALUATION IS REQUI P BY THE BOARD OF A TH: Conditions exist which require further aluation by the B of Health in order to determine if the system is failing to protect the public health,safety and the environmen . 1) SYSTEM WILL PASS UNLESS BOAR OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT TH P LIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 f t o a surface water Cesspool or privy is within 0 feet of bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD F HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT TH�`SYSTEM IS FUNC IONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorp 'on system and is within 100 feet to a surface water supply or tributary to a surfacce"water supply. Thersystem has a septic tank and soil absorptio system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption m and is within 50 feet of a private water supply well. f /.' The system has a septic tank and soil absorption m and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform cteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. i 9� OTHER lJ ,\ (revised 11/03/95) 2 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (� .� C Owner. ° Date of Inspection: , D) SYSTEM FAILS: 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. Backup of wage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pon ' 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 bution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less t �6"below invert or available volume is less than 1/2 da ow. Required pumping more than 4 times 3n the last year NOT due to clogged or o cted pipe(s). Number of times pumped 4 ' Any portion of the Soil Absorption System, aspool or privy is Belo the high groundwater elevation. Any portion of a cesspool or privy is within 10 feet of a ce water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zo of a public well. Any portion of a cesspool or privy is wit ' 50 feet of a private water supply well. Any portion of a cesspool or pri less than 100 f t but greater than 50 feet from a private water supply well with no acceptable water quality anal is. If the well has bee analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile c compounds,ammo ' nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following critee apply to large systems in addition to the trite ' above: The system sgrves a facility with a design flow of 10,000 gpd or greate (Large System)and the system is a significant threat to public health an/afety and the environment because one or more of the follo ' 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 \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 bring the system and facility into full compliaaoe 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a ar - Z�/& U (�+ Owner. Date of Inspection: Check if the following have been done: L-lumping information was requested of the owner,occupant,and Board of Health. ` 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. built plans have been obtained and examined. Note if they are not available with N/A. Tge facility or dwelling was inspected for signs of sewage back-up. _i'he system does not receive non-sanitary or industrial waste flow lie site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. 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. _The size and location of the Soil Absorption System on the site has been determined based on existu►g information or approximated by non-intrusive methods. _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION Property Address: Owner. �J Date of Inspection. FLOW CONDITIONS RESIDENTIAL Design flow: (J ltons Number of bedrooms: Number of carient residents: Garbage grinder(yes or no):_i/c) Laundry connected to system(��or no): /J Seasonal use(yes or no):! lJ Water meter readings, if available: d d 17 Last date of occupancy. 7 COMM ERCIAL/INDUSTRIAL• Type of establishment: Design flow: Grease trap present: (yea or no)_ Industrial Waste Holding Tank present: (yea or no)_ Nomaaaitary waste discharged to the Title 5 es or no)_ Water meter readings,if available: Last date of occu OTH (Describe) -date of oavpaacy: GENERAL INFORMATION PUMPINGti-RECORDS and source of in oration: , — !�61 / System pumped as part of inspection: (yes or no O If yes,volume pumped: . • .gallons Reason for pumping: TYPE OF��TEM =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) APPROIQMATE AGE of all components,date installed(if known)and source of information: 19 � Sewage odors detected when arriving at the site:(yes or no)A--"L) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7L Owner. Date of inspection: _ /—L, P� 1 Z SEPTIC TANK V (locate on site plan) Depth below grade: / y � Material of oons`fruction:�'i ante_metal_FRP_other(mplain) Dimensions: Sludge depth:1® Distance from top of sludge to bottom of outlet tee or baffle•_ Scum thickness: P l� Distance from top of scum to top of outlet tee or baffle:. /l Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or bafn , dept of liquid level in relation to outlet invert, structural in grity, evidence of leakage, etc.) c4A =,C1 d GREASE TRAP:_ (locate on site p ) Depth below grade: Material of construction: _con metal_FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of out or bafne: Distance from bottom of scum m of outlet tee or baffle: Comments: (recommendat' for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet vent,structural integrity, evidence etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. (/ Date of Inspection: TIGHT OR BOLDING TANK:_ (locate on site p Depth below grade: �• Material of oonstruction: concrete metal_FRP_other(explam) Dimensions: Capacity: =non$ Design flow: pUons/day Alarm level: Comments: (condition of inl condition of alarm and float switches,etc.) ° DISTRIBUTION BOX- �J (locate on site plan) ,r Depth of liquid level above outlet invert: Comments: f (note if level and dirtnbution is ual,evidence of solids carryover,a 'dence of leakage into or out of box,etc.) Q 1 �Pts'f BER._ (locate on site p Pumps in working order:(yes o) . Comments: (note condition of pum r,oondition of pumps an a ces,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ! f PART C SYSTEM INFORMATION (continued) Property Address: 76 Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): non-intrusive methods) (locate on site plan,if possible;excavation not required,but may be approximatedby • If not determined to be present,explain: Leaching pits, number: Leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields,number, dimensions: overflow cesspool, number: Comme ts: (note condition of soil, signs of hydraupc failure, level of ponding, condition pf vegetation,etc. CESSPOOLS:_ (locate on site p 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&oil,signs of by failure, level of ponding, con ion of vegetation,etc.) PRIVY: (locate on site ) of construction: Dime ions: De of solids: tits: (note condition of soil,signs of hydraulic failure,Level of ponding,condition of vegetation,etc.] (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. ► Owner: Date of Inspection: f -J—, f.7— --� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a9-- d 13 C , 1 � t� - 3.2 DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: - (revised 8/15/9S) 9