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HomeMy WebLinkAbout0016 PEARL ROAD - Health 16 PEARL ROAD, CENTERVILLE A= 247 223 fF k. 5: UPC 12543 Mo. 53LOR aF HASTINGS, '10 v TOWN OF BARNSTABLE _.00ATION SEWAGE # 1,gLLAGE CQ.t Y )eAVk L4-- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER �t►v-L_ +£off DATE: I�� S�5j-COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the h 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) I,*,, Feet Furnished by ,Y.,O a UO a 4��i L- O CAT I N SEWA !,k!P,,ER M I N0. VILLAGE INSTA LLE,R'S NAMyES� & AjDRESS ; B UILDE OR OWNER DATE PERMIT 13SUEDrrP� DATE COMPLIANCE I'SS'*�IED z � �� � _ � ` `� �i �G- �/ . �`•- � . � No..---. ............ Fxs... .s�.aU• •- THE COMMONWEALTH OF MASSACHUSETTS 2c; BOARD OF HEALTH L ................................----.....OF......................... ppliration for Disposal Works Toustrnrtion Vamcit `Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst t stem . •-•-- --•.. ....................... .-:ation.Address //_ or Lot No. p W / �`��- Address a ..............................=•-•..:.............. ........ /.,cvrr__ _._... ............................................ Installer Address Type of Building Size Lot.Z��_ .Sq. feet .., Dwelling—No. of Bedrooms................ ........................Expansion Attic Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures •-........-------•------------------------------------------•-----------........._.......__._...-----:... W Design Flow...... ..^..............................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.gOv_gallons Length................ Width................ Diameter__.--___-___--_ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. > Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ trq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ ------...---••--------------•-------------------•-••-----------.....--------•-•••••••--•---••-•.......-•----•-•••------•--------:.......------•-••••---.----- O Description of Soil.......................................... -•--------•-... ----------------- W U Nature of Repairs or Alterations—Answer when applicable._.......................:................................................................ .... ----------------------------------------------------------•-----------------------•--------•.......--------•••---------••------•-------•----------•---------••--••-•-••----------------------......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'!Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ���.L ---I 41—�-�....---- Application Approved By......... :�� D to27 Date Application Disapproved for the following reasons---------------=----------------------------------------•----------------------------------------------.......... ---------------------•----------------------•------------•-------•--....-•-------•---------•-•----------------------------•---•--•-------•---------.---------......................................... Date Permit No.................... -/ — / 7 . ..........--•-----•-•--------------- Issued_•-- -•----------•�-----------•-- ---........ Date -r No.......f.. ............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................--......OF...................................... Appliration for Disposal Works Tontitrurtion jJrrutit .,, Application is hRreby made for a Permit to Construct or Repair an Individual Sew alge Disposal Slystat:..... ......... Z_ x LP_Vr,....... ............................................................ .............................................. Location-Addr or w-er .......... No. -------------------------- ................ ...................... ..... .... ...................... wner Address .......................... reai �Z 2....... I ............................................................................. Insta ler Address /a Type of Building Size Lot.. z----------------Sq. feet U Dwelling—No. of Bedrooms.............. ........................Expansion Attic k Garbage Grinder Other—Type of Building ............................ No. of persons........_________._......... Showers Cafeteria PL4 Other fix .. .5- Design Flow..... Imes ..................................................................................................................................................... ...................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid*capacity../a,,a4f.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. f t. Z Other Distribution box (;K) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... 0-4 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........._.............. 11 1 .............................................................................................................................................................. 0 Description of Soil...................... .......................................................................................................................................... . ,,or 7'.......... ............. qu ..................................;... .. ....... ........................................................................................... -------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------....................... U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------................................. ....................................................................................................................................................................................................... Agreement: e The undersigned agrees to install titre. h.e. aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLIT12 5 of the State Sa nitary Code—The undersigned further agrees not to place the system in operation until a Certificate Cd ianchasbe"6nissied by the boar of lth. ............... ........ .......................... Signed..b.............. ...... ........, 3�< Date Application Approved By.............. I ,// ...................... 7 _4pr" Date Application Disapproved for the following reasons:.....................................................• ...................................................... ..................................................................................................................................7-------------------- --------------------------------------------- Date Permit No.. 110 ---------------------------- Issue 9 . . ------------------ d....................................................... Date Tk,F000MMONWEALTH OF MASSACHUSETTS % ........... BOAR Eg� .. .......................OF...................................................._.,.,................................ (Intifirate of Toutpliatta THIS IS TO CERTIFYJD?t4t0%,ki�lvidual Sewage Disposal System constructed or Repaired b ,7�#'Aye, y----------------------------------------------------------------- --------------- at.............. ------- ......----------------I-------- ....................................................... ...................................... ........ ........ ---?r-ted in------- has been installed in accordance with the provisions of TITLE 5-pfi The State Sanitary Code a?i - ' the application for Disposal Works Construction Permit No......................................... dated_-...-----....___........._..___......._.__..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------..................................... ................. Inspector................................................................................... Til. THE COMMONWEALTH OF MASSACHUSETTS BOARDf F HEALT ..................................OF................................................................ .............. No................... ... FEE........................ Permissionis herely granted........................................................................................................................ to Construct or Wepair,$ 4R�),S pividual ,�eyag�j Disp64!y6t atNo.........................................................................................................................................7 Street as shown on the application for Disposal Works Construction Permit No..................... Dated....._..___..__........................... ..................................................................................................... Board of Health DATE.W......................(7....................................... )k FORM 1255 HOBBS & WA.RREN. INC.. PUBLISHERS kj 0 T. 4, j 74, f i IT u aL l caoo G4- i lgF•. r i .C> 5p G.PD. td' - c;—i I'•L TJE:SiGt.t = 4ZS G.RD. y Gvlsl. KIM rn r•cat I_�f Ft1� = 33D 6.PU. r- r Clff t1� r,:C.OL&T%OLJ S wre CIQ SAAl0, OtZ t16;. _ - r / E4 { I 1 � � 4 ' y' I Ape �omo I iA/. 'ri 1 Rob -2 r 'pax ,,5 SEQr'Ic i e. ! iD rt�•p t OLD LEAC.�t 'a P►T h wasu>~v �1 CCL't'tl=tEt� pt_©7'-_ Pt . '�.►-.t t - �- �---_--•�-�- L aCAT't u l,.f �.l`�la 1a1 I��C / I _ �s-, ►.l o G .L.E C 1Z L-v �W A r T t4 C-- R k r'E✓r�L►�!{y ' ( � t-:r�t.,r G«•�Pt.�� vJ►�rl-t 't}-'sue '�l v;�' �t�-�� L....G`-i'" �.. tZCsGt•"f�_tiE.C� i-,�lJ� �v�•.��, .ti l ' p! .!` 1 lam; QOT [',AeyCV OW AW G + iCC�lit_lf to /r'C'�'�•:. /I �{ .! _PAL-. csC=l~'�c_C'ri 4i�GW X> t11�{'t �t_.fT'. [ '.✓�� LE� i t 1 -� ► � !, ; �''.r l,k_I�1 r.,i i,:: �"4' t,.1 Ni;:�.i ...""'k' � a COMMONWEALTH OF MA,SSACHUSETTS REcV ED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS'` NOV 2 5 1998 DEPARTMENT OF ENVIRONMENTAL PROTECTION TOWNOFBARNSTABLE . ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 ` NEALiHDERT ,� �r-r., i G• + . WILIIAM F.WELD TRUDY`COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Lt. Governor Comn,;«ioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtiI PART A L.o,r/ P \ _ CERTIFICATION' ,Property Address: ` �i��L=-� � ` ( ��""�� �—' Address of Owner: IJ.AlkwN 1' .vGs\c,i►.-L Date of Inspection: �I l iZ\� (If different) a63 LAN,CAsac.2- tt4 tiame of Inspector: Mur I am a DEP approved system inspector pursuant to Section 1:.340 of Title S (310 CMR 15.000) `�.b Company Name: T r1 L Mailing Address:-!?. (-) �,��,t-4 P�',v� r -e Telephone Number: CERTIFICATION' STATE.NfEN7 I certify that I have personally inspected the sewage disposal system at this address and that the information repored below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Ev lu io By the Local Approving Authority ails Inspector's Signature: �JY Date: _ J The System Inspector shall submit a copy of this inspection report to the Approving Authority within thiry (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 re7Ur[ to the appropriate regional office of the Department of Eavironme teal Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. { USPECTION SL1\LILARY: Check A, B, C, or D: s I AJ SYSTEM PASSES: r 1 have not found anv 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. CONBIENTS: 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". P w explain h • not. ) The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04l25i97) P2ge 1 of 10 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken..settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FLRTHER 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 protec: the public health. safety and the environment. 1) SYSTEM N�ILL PASS UNLESS BOARD OF HEALTH DETER.NtLNES THAT THE SYSTEM IS NOT FUNCTIONING INN A NLA_NNBR NNW-CH «"ILL PROTECT THE PLELIC HEALTH A.\'D SAFETY A.N-D THE E\VZRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM «ILL FAIL UNLESS THE BOARD OF HEALTH (AN-D PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER_NfIN'ES THAT THE SYSTEM IS FUNCTIONING L\ A NLANNER THAT PROTECTS THE PUBLIC HEALTH A_ND SAFETY ANI) THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public Ovate: suppiy 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 i water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25i97) P3gn 2 of 10 • Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. I Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year 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 fee: 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 fee: 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. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within'200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area -IWPA) or a mapped Zone U 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 CNIR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised MZSM) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART B CHECKLIST Property Address: Owner: ��J�-41Ct Date of Inspection: Check if the following have been done: You must indicate either "Yes' or "No" as to each of the following: Yes Na _ 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 recently or as part of this inspection. 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. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components. excluding the Soil Absorption System. have beta located on the site. A _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of battles or tees. naterial 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. !� Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue. approximation of distance is unacceptable) (15.302(3)(b)] t i (revised 037:5i97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ';operty Address: )weer: )ate of Inspection: 1`1Z`c-1(0 FLOW CONDITIONS ,ZESIDENTIAL. Design flow:*3 U e.p.d./bedroom fQr S.A.S. Number of bedrooms: Vumber of current residents:A ',arbaee grinder (yes or no):­6� t.aundry connected to system (yes or no): seasonal use (yes or no):_LJ Nater meter readines, if available (last two (2) year usage (gpd): _.ump Pump (yes or no): t,-S Last date of occupancy: �M CONnIERCIAL/TNDUSTRIAL: Type of establishment: Design flow: eallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S systern: (yes or no)_ Water meter readines, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GE. —AL IN NLATIO` PL.%PL\G RECORDS and sourf a of information: i7�, ttnn�c �VL:2I 7U )LS �� lylat�vl �l)Cz 0wivelL� System pumpe as part of inspection: (yes or nuT I If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes. attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIAt-kTE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revurd 04.:5/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: Owner: Date of Inspection: BUILDING SEWER: If CS (Locate on site plan) t1 Depth below grade:�z Material of construction: _cast iron 40 PVC _other (explain) Distance from IFrivate water supply well or suction line '�04ZW Diameter 1 _ Comments: (condition of joints. venting, evidence of leakage, etc.) Kn�z0.SCF t SEPTIC TANK: Fj (locate or site plan it Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(YesiNo) Dimensions: (D V., I - Sludge depth: .-1'( Distanct from top of sludi:e to bottom of outlet tee or baffle:_ Scum thickness: tt t Distance from top of scum to top of outlet tee or baffle: P, tt Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: 4' ,,GI,m,,Z-CA Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation t outlet inv structural inte_rity. evidence of leakaee, etc.) tL t Da �^ ( ( V T —k V GREASE TRAP:;;_ (locate on site plan) tt Depth below grade: 4 Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) i 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.) (revumt 0-4/:5M) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.M PART C SYSTEM INFORMATION (continued) Property Address: Ptuu.l� Owner: 1&?w.' 1 N� Date of Inspection: L r Ack(6 ' 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 level: Alarm in workine order _ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) tISTRIBL'I'IO\ BO\:� 0 (locate on site plan) �t Depth of liquid level above outlet invert: va G'j Comments: (note if_Level and(.distr�ib_t!�\jn is eeaal, a^iden`ce,of solids ar;}yover, evt�ce of llezk2ce ' to.or t 0 box, ne:c.) L�k' Vt �t.�(/ �1!' +t� Pn' P CHkNBER: (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 0.41:5%9') Pa&e 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �0 Owner: �Xa." ' Date of Inspection: I� I SOIL ABSORPTION SYSTEM (SAS): UM (locate on site plan, if possible. excavation of required, but may be approximated by non-intrusive methods) If not determined to be present. explain: Type: leaching pits, number: (vIL lv leaching chambers, number:_ leaching galleries, number: leaching trenches. number.lenvth: leaching fields. number, dimensions: overflow cesspool, number: Altemative system: Name of Technology: Comments: (no a condition of soil. signs of by aulic failure, level of ponding, co ition o egg ton, e:c.) 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: 6 inflow (cesspool must be pumped as part of inspection) I 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.) (rcrued WiZSi9i) Page 8 of 10 y. SLBSLiRFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART C Q SYSTEM I1r'FOR ATION (continued) 'roperty Address: )uAmcr: )ate of Inspection: b 4CETCH 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) 1F G� 1 i { o „ t (re•ucd 0-t:25,9-) Pile 9 or 10 SUBSURFACE SENVAGE DISPOSAL SYSTEM LVSPECTION FORUM PART C Sl'STE`t E'FORMATION (continued) Propertv Address: t�a��a�� Owner: Date of Inspection: ` ( 24 r` f I Depth to Groundwater �S Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Mj.r> Check pumping records Check local excavators, ins;ailcrs Use USGS Data -' �� H:Lh Ground-.%atcr E ovation Must be eomp;c:c.:1 4Q DC�CrtCC I. YJfCr C'x'�-+Cr��('h0�u �'p� eSt1�.US�. Ii.. �� Uts� 2O( SZ1C,C� aCJ`� �(�1'��I'v �g lit i 3 i 1 (re�uml 04.__ 97) Page 10 of 10