HomeMy WebLinkAbout0096 HOLLY HILL ROAD - Health 96 HOLLY HILL ROAD, CENTERVILLE
A= 188 092
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�llln J��cwaF,�
NoP_ 12534
_
HASTINGS,MN
TOWN OF BARNSTABLE
LOCATION q b ND�AN \1\�`1 1 e,D Ck4. SEWAGE..La0lS -XVOk
VILLAGE C nA-F,YV ANJ ASSESSOR'S MAP&PARCEL 7
INSTALLER'S NAME&PHONE NO. SVC�`�MQkYI'�X C (N��YiCn�`.�
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) ft� Sou yJ (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: �] COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) /i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility �/� Feet
FURNISHED BY
� T
�-= V4
Cr ! l TOWN to
ARNSTABLE
/
LOCATION I`� `��I Y f � [moo I SEWAGE #
VILLAGE ` lam ASSESSOR'S MAP & LOT 01Z
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY X1JF,Oy3 (A,�POo 1 (K (•y
LEACHING FACILITY: (type) ��1Q�-�`tx+J 0®) (size) (n
NO.OF BEDROOMS
BUILDER OR OWNER, (7-erJAt)
fEfd*FFDATE: l `i COMPLIANCE DATE: 1��(
Separation Distance Between the: t
Maximum Adjusted Groundwater Table and Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N dA Feet
Edge of Wetland and Leaching Facility(If any wetlands exist j�f
within 300 feet of leaching facility) . Feet
Furnished by
-1�e
.,
�/' Z
�1 —�.5
�� ��� �Z_ dd r
ev�s�� f
No. a4�_ / Fee
HE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4pliLation for Bispo8al *pstrm Construction permit
Application for a Permit to Construct 1` Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.�' 1 ��11'(3 tV�l Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel t\ p p` D q--a_ F(O`Y\W N 6Y�av� q�'ballt�1�vc`ol`
�c
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
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 JW gpd
Plan Date \)( � �� Number of sheets Revision Date
�
Title
Size of ti,Septic,,Tank Type of S.A.S.
Description of Soil ' `-e.601jr/ 5(11'1_(\
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 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 s B4offl�
ig d "+► d Date
Application Approved by Date
Application Disapproved y Date
for the following reasons
Permit No. Date Issued
\` } $j •../ III,
No. Fee
HE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
t�
M5' Yes
PUBLIC HEALTH DIVISION - TOWN-OOF BARNSTABLE, MASSACHUSETTS
application for Disposal bwstrm Construction Permit
Application for a Permit to Construct('� Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.�(o HOI��I �`�� Q CQn vv,�� Owner's Name,Address,\and Tel.No.
Assessor's Map/Parcel p� �v 0 q�. F���� S N o,r�
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
S"pea�mc�nEcc�. �S5geoxv
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
I
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) (�X 3 ' �j�j(} gpd Design flow provided gpd i
Plan Date -7 (c,I I Number of sheets Revision Date
Title`j r Q» a l���CFa�d L 0 Y\51 A
Size of Septic Tank ` Type of S.A.S.
ki
C Description of.So�'
Nature of Repairs or Alterations(Answer when applicable)
ie 3ti 4
Date last inspected:
Agreement'
i
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-tI�Board of H lth.
ig d /.c. Q,' ' n Date
Application Approved by ZX Date
Application Disapproved by Date
for the following reasons
44
Permit No. Date Issued
r �
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance ,
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by �/
at , y 1 as been constructed in ac r Ace
/ J
with the provisions of Title 5 and the for Disposal System Construction Permit No d ed �( `'►
Installer Designer w
#bedrooms Approved dgftqflA
3W gpd
The issuance of thi pet it shall not be construed as a guarantee that the systemtl�l�funi h as design
Date 110 Inspector
I
- ---------------------------------------------------------------------------------------
r / Fee /1 /,/ 9__1-
No. �,t�i
7 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construrtlon 3permit
Permission is hereby granted to Construct(� epair( Up�( ) and n )'
System located at I�
� r
i
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.
;f
Provided:Cos 7!tioAust eQompleted within three years of the date of this permit.
Date Approved by j
Town of Barnstable
ofIMEr°'►y Regulatory Services
Richard V. Scali, Interim Director
aAmsrasLE,
MASS. Public Health Division
i639• ��
Thomas McKean, Director
200 Main Street, Hyannis, VIA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date: Zl ZDI� Sewage Permit# a"OA at Assessor's Map\Parcel
Designer: C�V P_ Cn(,A Car Installer: ����� C 1Q� L�-C
Address: �W14 Address:
On -�J)\1 PAS S � ��C CQ�e�1��'�iL,issued a permit to install a
(date) install r)
1
septic system at � 'I oo based on a design drawn by
(address)
MCX`doY� dated,
(designer)
ZI certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed ' I.innce with the terms
of the I\A approval letters (if applicable) / �;�0`�,�,#`e �
AVID
Installers Signature �, f ki SON !;
(Installer's ) � rho.1066"` it
All
esig atu (Affix Desip :� p Here)
PLEASE RETURIN TO BARINSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COiV>PLIANCE `VILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Designer Certification Form Rev 8-14-13.doc
Town of Barnstable P# I`{ T
44 Department of Regulatory Services
a�tat�.i
Public Health Division Date ��6— L00/ S
� 200 Main Street,Hyannis MA 02601
Date Scheduled e Time Fee Pd.
r;
'l Suitabilify,Assess nt for Sew a Dis osal
{�p{�oARp r
Pvtivm•w or: .._ W101EiSSEd lly�L J 1_ ,vr,5b
LOCATION&GENERAL INFORMATION
I.ocationAddress , �,Ja_t Owner's Name �C�h.Q.9 S 11fv_.1'1
C� Address
d env t��. M a ab3a ,, �r•�� ►.,.11, bah a
Engineer's Name a 1LmoL Y) 0Y1S� 5�
Assessor's MaplParcel:m�p u, yo.Tc�,1: �q`a. nSv4
NEW CONSTRUCTION REPAIR Telephone#1-1
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area R Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
�I
Parent material(geologic) (epth to Bedrock
Depth to Groundwater:Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_
PERCOLATION TEST. _....-»at: . Time
Observation Time at 9"
Hole#
Depth of Perc Time at 6"
Start Pre-soak Time @ Time(9"-C)
End Pre-soak
Rate MinAnch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back----
***If percolation test is to be conducted within 100'of wetland,you must first notify the I
Barnstable Conservation Division at least one(1)week prior to beginning. �11
Q:\SEPTIC\PERCFORM.DOC
try
t DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stnrcnue,Stones,Boulders.
Consistency-11 %Gravel)
f
I
1 (1
j i 1
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%(iravel)
Flood Insurance Rate Mao:
Above 500 year flood boundary No-/es
xes
Within 500 year boundary No IIC Xes_
Within 100 year flood boundary No_ Yes_
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervl a r'al exist in all areas observed throughout the
area proposed for the soil abso lion system?
If not,what,is the depth n Ily occurring pervi us material?
Certification
I certify that on (date)I have passed the soil evaluator examination a proved by the
Department of E14�a'Protal ection d that the above analysis was perfo ed y me consistent with
the r ing ex rt expe en a described in 310 CMR 15.017.
Si e Date
I
Q:\SEFnC\PERCFORM.DOC
• COMMONWEALTH.OF M4SS?►CHL'SETTS .
: 'N L AFFAIRS
'ti 0�. 4E. TA
� r F?�ECL'TI1r E OFFICE OF E.'VIR
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02106 E1!•-9:•`:{'G
• TRLMY CON!
w1uaAM F.WELD
. "•: ,:• DA*%ID B STRL:I
ARGEO PALL CELLL'CCI Commission-
Lt.Gavinmai SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM^••
v t q_ tchr8 PART A
: .
CERTIFICATION
�Cn ram;
Property Address �1 k ►� P `' ` l `' =; Address of Owner: :�,�t?N,cA�(�..�j2No�c9L.
P P �1' '(If different) 1 I:CQ dtb Cc�v��-cam hoc, t¢. wa.�
Date of Inspection: �j nn' Cjpp���-dam V� Z
Name of Inspector. 4r &V D i•' Ed=Cem
1 am a DEP ap roved system inspector pursuant to Section 13.340 of Title 3 010 CMR 13.0001
Company Name:A� o r.,4-,e 4!;_1+ Alp l 011'r-7•.4 we P w - -/
Mailing Address: 2 Q f ox P32F CU H -er 0 e-6-4.51 .
Telephone Number: rSG
CERTIFICATION STATEMENT
1 ce:af) that I have pe•sonally ir!speeed the sewa¢e dapcsa! syster at this address and tha: the information reported be:o% is true. accurate
and comole:e as o=the time ai tnspee.,a The rnspect:an wa! pe�ormer bases on rnv training and experience in the-pm-per funds:: and
maintenance of on-site sewage disposa; systems. The mterr.: '" i ' t !. ,•r
v Passes e$'
_ Co.1c t.o^ail% Passe!
1eec: Furthe• Ev lua E Local Ap;rovinj Authority ' . IV4
1998.
Inspector's Signat e: Date: q�Nsr 1
rFPjAe�f
7:Ie Svs.e Ins -a, sha'' submit a cop%- of this inspection reoc:. tc the Aporo�ing Authority within thirty• 001,days of compietin this
inspection. It the systen is a sha►ed systern o• hat a de:,gn flow o; 10.000 god or greater, the rnspe:or and'`th�efC is,m owner sFb11 submit
the repon tc the appropriate re_,ona1 oii,ce of the De;a-meat of Envirenmenta' Protection. The original should be sent-to the systern o ne-
and copies s-•t;to the buyer. it applicable. and the ap-craving authority
INSFECiIO% SUMI%WY: Check A, .B, C, Or
Al SYSTEM PASSES:
1 Have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 13.303.
Any failure.cnteria not valuated are indicate: below. .
COMMEtv75: fa'1 r �
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired.. The system, UPC
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes• no, or not determined (Y, N. or NDi. 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 (201 years prior to the date of the inspection: c
the septic tank, whether or not.metal, is cracked, structurally unsound, shows substantial infiltration or exfiltrat)on, or tan
failure is imminent. The system will pass.inspection if the existing septic tank is replaced with a conforming septic tank
A! approved by the Board of Health,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
:. CERTIFICATION (continued)
Property Addwss: Y . , . J
Owner:
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES ltonunu� - •_
' Sewage backup or'breakoui or high static water level observed in the distribution box i due to broken or obs;ruaed
pipe:s) or due to a broken. settled or uneven distribution base. The system will pass i spection if(with approvat of the
' - Board of HealthJ. Describe observations:
broken"pipes) are iepfaced
obstruction.Is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to brokers r obstructed pipe(s).:The system will pass
inspection if twith approval of the Board of Health): -
broken pipetsi are replaced _
obstruction. is•removed _
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:7.
Conditions exist which require furthe•evaluation by the Board of aith in order to determine if the systerrs is failing to protectthe
public health, safe:y�and the environment - -
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI ' 5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFE AND THE ENVIRONMENT:
_ Cesspool or prn% is within 50 fee:of a surface ater - _-
Cesspoo! or pr,%N- is within 50 fee: o-'a border g vegetated wetland or a salt marsh. -
2) SYSTEMM WILL FAIL UNLE55 THE BOARD OF HEA H U1ND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM I5 FUNCTI0ti11G"IN. A MANNER AT PROTECTS THE PUBLIC HEALTH AND SAFFEFY AND THE
ENVIRONMENT:
The sys;em has a septic tank and s absorption systern (SAS, And the 5A.5 is within 100 fee:to a surface water supply or
tributary to a surface water supol�.
_ The system has a septic tans, an soil absorption systern and the SAS is within a Zone 1 of a public water supaty we!I.
_ The syste-n has a septic tank d wil absorption system and the SA.S is within 50 feet of a private water supply well.
_ The syste•n has aseptic tan and soil absorption system and the SAS is less thar. 100 feet but 50 feet or more from a
private water supply well, mess a we!I water analysis for coliform bacteria and volatile organic compounds indiates the
the well is fre-- from poi tion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to C
less than 5 ppm. Met used to determine distance (approximation not valid).
3) _ OTHER
page 3 at %a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% .FORM
PART A
CERTIFICATION (continued)
Property Addross:
Owner:
Date of Inspection:
D) SYSTEM FAILS: t ;:
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 d ined in 310 CMR 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to det rmine 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 groun/tclogged
e w ers due to an overloaded or clogged SAS or
cesspool.
Sta:ic tiouic level in the distribution bo> above outlet inververloaded or clogged SAS or cesspool.
lrcuid depth in cesspool is less than 6- below invert or avame is less than 1/2 day tlov.
Reouired pumping more than, 4 times in the last year NOTged or obstructed pipes.
Number of times pumped_.
Any portion o the Soil Absorption System, cesspool or prigthe high groundw�ate• eievatiorAm por.on of a cesspool or priv-v is withir. 100 feet of a r suppl%•or tributary to a surface Hater supply.
Any porion of a cesspoo! o'r,pri%i- is,w dhrn a Zone I of public'well.'
An% a cesspool or privy is within 50 feet a private water supply well
pt ~lo- of
Am• por,,or. of a cesspool or privy is less than 10 feet but greater than 50 feet from a private water suppl%, well with no
acceotable Ovate, qualir\ analysis. If the well ha been analyzed to be acceptable. attach cop,,- of well water analysis (or
coliiorn: bacteria volatile organic compounds, mmonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: -
You must indicate ei her "Yes" or "No" as to each of the foil ing,
The ioliowtng criteria app;% to largo systems in ad ition to the criteria above:
The system serves a facilin with a design flow t 10,000 gpd or greater (large System; and the system is a significant threat to
public hea!th and safer? and the environment cause one or more of the following conditions exist.
Yes No .
the system is within 400 feet of surface drinking water supply
the system is within 200 feet f 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 bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 Cti1R 5.00 and 6.00. Please consult the local regional office of the Department for further iniormation.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARZ
CHECKLIST
Property Addcess: 96 Kv�l '�II
Owner: Crjl 06vecv V
Date of Inspection.
��y� ,
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.
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 recentl% or
as part of this Inspection.
ined. Note if they are not available with NIA.
As bu+l; plans have been obtained and exam
The fac:llr.� or d,%ell+ng was inspected for signs o!sewage back-up.*
Tne system does not receive non-sanitary or industrial waste flow:
_ The site %%as Inspected for signs of breakout.
_ All 5vstem components. excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes %ere uncovered. opened. and the interior of the septic tank was Inspected for condition of
bafiies or tees. mater+ai. o' construction. dimensions, deptn 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 fac-lio. o%%ne• ,ano occupants. if diiteren: from owner) were provided with Information on the proper maintenance of
Sub-Suriace Disposal System.
/'�• _ Existing Iniormation. Ex. Plan at B.O.H.
Determined In the field !r am of the failure criteria related to Part C is at issue, approximation of dis:ance is
fff"'ccc unaccep:abie [15.302t3):b'?
(reviled 04/25/571 ?age'{ of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propert% Address: 9L lofty 1h1I
Owner:(Pe NG✓P} i G
Date of Ihspection:
FLOW CONDITION'S
RESIDENTIAL:
Design ilov, v p.d./bedroom for
Number of bedrooms
Number o°current residents-
Garbage
&'v der (Yes or no!:=fi� .. ._
Laundry co-•^ected to system (yes or nol. _ --.,.--._.__._..._ _.. .__ .—_-•- . _ _ ._�...
Seasonal use ryes or no!:�
Water meter readings, if avail ble (last two (2,year usage tg'pd):
Sump Pump Ives or noc _ ,
Lac_date o'occupanc%- W VSt? ..
COMMERC i 4L'INDL'STRIAL-
Type of establishment
Design fiovv• galionsida%
Grease trap present. ryes or no_
Industna! %'taste Holding Tani: present. eyes or no
':on-sanrtan %%ante discnargec to the Tree 5 system. ayes or no
X%ater meter readings. if ayailabie
Lastpa:e o: o
OTHER: .Deicnbe
Last care of occuoanc.
GE%ERAL INFORMATION ,
PUMPING RECORDS and Sou ce of iniormation,
System pumped as par, of inspection: (yes or nol�_D
If yes, volume pumped- gallons-
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
_ Single cesspool 16��tvt FIo(� ty 1
Overflow cesspool l
Privy
- Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: �our�-�
Sewage odors detected when arriving at the site. (yes or not
(revised 04/25/91) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: _..
Date of Inspection:
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 h-:
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site play
Depth below grade
material of construction: _concrete _meta _Fioerglass _Polyethylene _ot rtexplarn ,.
It tank is metal, Lis: age Is age confirmec o% Ce-t:iicate of Compiiance (lres`No
Dimensions
Sludge depth
Disiance irom top o: s!udge to boron o-outie: tee o• ba;;e
Scum thickness
Distance from top os scum to top o' outlet tee or,ba-ie
Distance iron bosom of scum to bo- -io^ 01 outlet tee e• bac.e
Flow dimensions were determined
Comments.
trecommendation for pumping. condition o� inlet and outlet t s or baffles. depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.i
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 out) tee or baffle.
Distance from bottom of scum to bono of outlet tee or baffle:
Date of last pumping:
Comments: _.. . , ..,.. .. .. __- .._ .._.._.._.....
(recommendation for pumping, condition of inlet and outlet tees or bafflei, depth of liquid level in relation to outlet invert, structural.
integrity, evidence of leakage, etc.'(
'I (revsaed 04/25:97) Page 6 bL 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C ,
SYSTEM INFORMATION (continue/
TIGHT
Propert} Address:
Owner: .
Date of Inspection:
OR HOLDING TANK: 'Tank must be pumped prior to, or at time, of insp(locateon site plan,
Depth-belowgrade.'Material of construction--� concrete _metal _Fiberglass _Polyethylene _other(ex ---• =— -
Dimensions: "--
Capacm^ gallons
Design flow. galsons'da.
Alarm level Alarm in working order_ Yes: _ No
Date of previous pur,ping `
Comments
(condition of inlet tee. condition o- a!a•m and float switches. etc.s ----~-- - -- -
DI$TRIBUTIO% BOX:_
locate on site pia,
Depth of houid level aoo\,•e ouue: imer:
Comments-
tnote r.'level and distribuuor,. is eoua• evidence of solids rn•over, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_.._....._..:.
..(locate on site plan; - .__..-..._._....._ .
Pumps in working order: (Yes or ho,
Alarms in working order (Yes or No
.:.__.._-. .._.._
Comments: ._.._.._..;._ ..._..._..._.._..__._..__.. .. _
'(note condition of pump chamber, condtti n of pumps and appurtenances,-etc.)
(revised 04 2S 97) ______pace 7 of 10
.y-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:.PART C _
SYSTEM INFORMATION (continued)
Property Addr-ss:
Owner: r��eNovq,
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):*,s
(locate on site.plan, if possible; exca%ation not required,but may be approximated by non-intrusive methods. �.
If not determined to be present, explain:
Ype:
- leaching pits number._ - - _._.__.__ __ ..__...__ ..---_-.---_____._._..._._ __ _...._._.....__.
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number,length:
leaching fields, number, dimensions
overflow cesspool, number —
Alternative system
Name of Technoiop-
Comments.
tngte condition of s il. signs of hgdraulicsf Stu e, level of po d�r}g. c dot n of vegetation, etc ---- - aN
t I
CESSPOOLS: _
(locate on site plar. ,)
Number and config ura: r.-o
Depth-top of liquid to inlet rover,
Depth of solids lave, Ire cl i
Depth of scum layer. A4
Dimensions of cesspool
Materials of construction
Indication of groundwate-
inflow tcesspool must oe pumpeC as par, of inspection)
Comments:
(no a condit',n of s il, st Gnssof hydraulic failur , leve of pon 'ng,_cond ion vegetation, etc.) 1
I r-j
PRIVY:.a� _.. . . _-- _ .. .-... _.
---Alocate on site plan) ...._...._ _....-- -- _. ............. _. .....
Materials of construction: _ Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of pondtng, condition of vegetation, etc.)
(revaaed 04/25/97) page 8 of 10
! r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuedi .
Propert}�ddress:
Owner:
Date of In5pection:�r���� •
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)
I 1p +
nA IC-1 in
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property ddres
/� .• .. .
Owner: �Cw�
Date of Inspeciion:
1
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
Cneck with loca! Board o• nea::^
Check FE..mA Maps
Check pumping records
Check local excavato,s tnstalle•s
l_se L cr•c Da-a
r,
Desciibe to vou, ow'-• woro= r.o•.• <o:: e5tabhshed the High Ground%ate! Elevation. (Must be completed:
U,S, �tO10 (tJ S�aL)S-� L dKo1o�jl C%�Nves�� --T1dv`'s', A_ LC� Z. 5'1 .fi 3�
(rev-sod 24.25,9'. page 10 of 10
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