HomeMy WebLinkAbout0139 PARK AVENUE - Health 139 Park Avenue
Centerville P
207 026
UPC 12"3
No. 53LOR 40 co
HASTINGS. LIN
I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
' c
,,• �, a RECEIVED
SEP 15 2004
TOWN OF BARNSTABLE
TITLE S HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
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Property Address: 139 Park Avenue
CentervilleY
Owner's Name: Egidiju Uzgiris I
Owner's Address:
A-
Date of Inspection: 9/1/2604
C-0 3 '
Name of Inspector: (please print) Patrick T. Sullivan 70
Company Name: Ready Rooter � 11171
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
il�Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
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.
Notes and Comments
""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.
v:
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 139 Park Avenue
Centerville
Owner: _Egidiju Uzgiris
Date of Inspection: 9/1/2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
C. System Passes:
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:
��• ice• � �� c� -� r— � �.�-• � Lv-oQ.i`�^'y ;.v� ��5_
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section eed to be replaced or
repaired.The system,upon completion of the replacement or repair, as approved by a Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND) in the for the following s tements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tan (whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure !s imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved the Board of Health.
*A metal septic tank will pass inspection if it is structurally noun ,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or igh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or une en distribution box. System will pass inspection if(with
approval of Board of Health):
bro n pipe(s)are replaced
o truction is removed
istribution box is leveled or replaced
ND explain:
The system required pum ng more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with appro I of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/l/2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fXnm
ation by the B rd of Health in order to determine if the system
is failing to protect public health,safetyronment.
1. System will pass unless Board deter 'nes in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a ich ill protect public health,safety and the environment:
Cesspool or privy is within surface waterCesspool or privy is within 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,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 ithin a Zone I of a public water supply.
The system has a septic tank and SAS and the S is within 50 feet of a private water supply well.
_The system has a septic tank and SAS and a SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to etermine distance
"This system passes if the well water alysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds " dicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and 'trate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/1/2004
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 and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Z 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.
_Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
- Any portion of a cesspool or privy is 50 feet of a private water supply well.
_,,Z-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 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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
(Yes/No)The system fails. I have determined that one or more of the above criteria exist as
described in 310 CMR 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 ith a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the followin
(The following criteria apply to large systems in addition to a criteria above)
yes no
the system is within 400 feet of a surface dr' king water supply
the system is within 200 feet of a tribu ry to a surface drinking water supply
_the system is located in a nitroge ensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water suppl well
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed. The owner or operator of any large system considered a
significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner s uld contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/l/2004
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 than owner)provided with 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:
Yes No
Existing information. For example,a plan at the Board of Health.
V _ 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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/1/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): '�D
Number of current residents: Z
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no);,,--�—Jif yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):j,3c:f�, =
Water meter readings, if available(last 2 years usage(gpd)):
Sump Pump(yes or no): A-x=>
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc,,
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or ):_
Non-sanitary waste discharged to the Titl system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records (�
Source of information: Xj'k:--, rrrs �cSr�vc—��
Was system pumped as part of the inspection(yes or no):L�j
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)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)
i ,
i
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/l/2004
BUILDING SEWER(locate on site plan)
Depth below grade:�—
Materials of construction:— iron Z0 PVC_other(explain):
Distance from private water supply well or suction line: 4,�IA
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Zlocate on site plan)
Depth below grade: i (!:j,,
Material of construction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: % �` x
Sludge depth: "
Distance from the top of sludge to bottom of outlet tee or baffle: 3Z)
Scum thickness: 3°
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: _
How were dimensions determined—
Comments(on pumping recommendation ,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
n v• 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 outlet te/tc.):
Distance from bottom of scum to bottom of ofle:
Date of last pumping:
Comments(on pumping recommendations,iee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakag
Page 8 of 11
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/1/2004
TIGHT or HOLDING TANK: (tank must be pumped at time 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(yes or no):
Alarm level: Alarm in working er(yes or no):
Date of last pumping:
Comments(condition of alarm and at switches,etc.):
DISTRIBUTION BOX: 3/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
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 chamb ,condition of pumps and appurtenances,etc.):
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/l/2004
SOIL ABSORPTION SYSTEM(SAS): �/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_j.Zleaching trenches,number, length: �A x X 0
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.):
r S. rS2
CESSPOOLS: (cesspool must be pumped asp 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 constructiorsoil,
Indication of groundwat no):
Comments(note conditiof 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 hydraulic failure,level of ponding,condition of vegetation,etc.):
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidi u Uzgiris
Date of Inspection: 9/l/2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A
Ar = tom `
B
oy
° 3
I�
Page l l of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Park Avenue
Centerville
Owner: Egidiju Uzgiris
Date of Inspection: 9/1/2004
SITE EXAM
Slope
Surface water
Check cellar V___
Shallow wells
Estimated depth to ground water> feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
_,'Checked with the local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_IZ-Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
1�
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f'j�o,'�i��W�'��ARNSTABLE
LOCATION ��.;,��� �,; ��� �'/ SEWAGE # .;-ti S�
VILLAGE ASSESSOR'S MAP & LOTZ407 -O-L�59X
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 1 tTO
LEACHING FACILITY:(type) )C(jr-k -6-(wck (size) 4 A'a y'1p i'
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �t9�a?s�o�
DATE PERMIT ISSUED: 5
DATE COMPLIANCE ISSUED: -5b,3 0-
VARIANCE GRANTED: Yes Now
. *r:x=.
NovSE
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cy 4
No. U - '' cc22
3.�.�.�.�............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Mirpitial EnrliB Tomilrnr#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
139 Park Ave Centerville
Location-Address or Lot No.
Walter Lendraitis
......................_.......................................................................... ---...............................................................................................
Owner Address
W 6V.E.. Robinson Se2tic Service.............. P.O. Box 1089 Centerville
Installer Address
d Type of Building Size Lot-----------------•---..-_Sq. feet
Dwelling— No. of Bedrooms.-----.--_--
------------------------------_Expansion Attic ( ) Garbage Grinder (no)
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter----.-.......... Depth................
W Disposal Trench— No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft.
x
Seepage Pit No-------- ------------ Diameter-------------------- Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------- ----- Date......................................0-1
..
Test Pit No. I................minutes per inch Depth of Test Pit._._-.._-.-_____-__- Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
ODescription of Soil..................... and-•-•--------•----------•----•----------•--------------------------------------------------------------------------------...........-•---
x
W ..............---..................................................... .................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable_-_in --a--- ---�a SeP..tic. ...talk-,
d-box & a 60 ' x 4 ' x 2 ' leachtrench
--------•-------------------•-------------------------------------------------------•--------------------------------------------------------------------....-----------------------------------..------
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 Compliance has be issu y b rd of health.
Signed . --------- ----------------------------------------
-
Dace
Application.Approved BY , . .. ...
......1.. ......../5
Dace
Application Disapproved for the following rearons: ............................................................................
------------------------------------------------------------------------------------------------------- ---- -------------------------------- ---------------------------------------------- -----...................................
Date
Permit No- ---------- --- L. . .
1 �-``J- �.7- - Issued .... ... -
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ter#ifi a e of Tomplian ce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed Y
g p y ( ) or Repaired ( )
by ....W.E Robinson Septic_..Serv-ice _....... ... - -- - ..._.........._........... -
-----------------------------------.. hs-:-----
1 3 9 Park Ave Centerville - --- -------- ....
at ------------------------------------------------------ ----------------------
has been installed in accordance with the provisions of TITI.E 5 of The State Environmental Code as described in
1.� .� .., .------- - 5---
the application for Disposal Works Construction Permit No. ......� ._-._......C'. - dated — ��.-:.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF 9ORY.
DATE. ....... .�...�� --------------------- Inspect { �.., -z� L-- � - I
--- ------- -------
---,-,_.-----_-.__.----_-,--_,-----,_---,---•-__-----------•_.---------- -- �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 30.00
........ FEE........................
Difipnottl Workii TAni#r ion "rrmit
Permission is hereby granted.... ,R.obj-nsarj—qe.0 _� �� �F ----------
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No....... 39...Park..A .. CQra�e�vi.l..1t' - --------
Street �'
as shown on the application for Disposal Works Construction Permit No.-73_-:: -U-Dated-------.�
------•------•---•------------ -----------------------
r �yB rd of Health -------•------.-
DATE-------------� -------•--•--------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
F
No...._!.. :.. 30.s.0.0............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH t
TOWN OF BARNSTABLE
Appliration for Uiopoottl Workii Towitrurtiou ramit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
139 Park Ave Centerville
......................•-----•-•----...-•---••---------------•-----------------------•-...._..._... ----------------------------------------------•-•----............----•-----------•-----------•••--
Location-Address or Lot No.
alter Lendraitis
Owner Address
a W.E. Robinson Septic Service P.O_._ Box 11._089 Centervil-1e-------------------------
Installer Address
d Type of Building Size Lot... ......... ..........Sq. feet
U Dwelling—No. of Bedrooms----------
----------------------------------Expansion Attic ( ) Garbage Grinder (no)
Other—Type of Building ---------------------------- No. of ersons---------------------------- Showers —
a yp g p ( ) Cafeteria ( )
Q' Other fixtures ------------------------------- --
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 W Septic 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 ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---- -------------------------------------------------------------------------------------•---•----••---•-•..............---------------------•------------
ODescription of Soil-------------------sand---------------------------------------------- -------------------------------------------------------------------------••-•----_-----
x
w
............................................................-------------------------------------- ---------------------------------------------------------------------------------------••-----------
U Nature of Repairs or Alterations—Answer when applicable.---.install.
_A Q---gal...aap x _. -.4.
d--box & a 60 'x 4 ' x 2 ' leachtrench
------------------------------------------------------------------------------------•-........_..-•------------------------ ------------------------------------------------------------........---•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Environmental Code—The unde_,rsig/n�ed further agrees not to place the
system in operation until a Certificate of Compliance has Lbeeissue -ley , e'b �r of health�---------- ---------------------------------- ........ ......
Date
Application.Approved BY ..... ..........r ,t-e.......7
Date
Application Disapproved for the following reafon.t: ..... ... ... ...................................... .............................. .............................
.......................... .. ................................... ............................................................................................................................. ..... ........................................
C w Date
Permit No. -----------I.....5 ........./-.9---- -------- Issued
Dace
L«._v.--------- ——— ———————————————————----