HomeMy WebLinkAbout0026 SHEAFFER ROAD - Health 26 SHEAFFER ROAD, CENTERVILLE
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UPC'12543 y •
No.53LOR
"AST(NQS.ION
�+ TOWN OF BARNSTABLE
i LOCATION oZ 9 (/,'15q P-F--Q WA). SEWAGE# 40//— y//
VILLAGEC2�1,TW'Qy,/le, ASSESSOR'S MAP&PARCEL/`Ie2-o 36
INSTALLER'S NAME&PHONE NOt*'-07400.o;(//�
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type)/r��/� asp(size)
NO.OF BEDROOMS 3
OWNER cJOiV ZG//�
PERMIT DATE: /oZ 6 P?0// COMPLIANCE DATE: dI IF
�y
Separation'Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
f�
AID 3�
3
q 3
No. ®16 s 1� L ` Fee 0 c
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLatlon for Misposal 6pstem Construction VPrmit
Application for a Permit to Construct( ) Repair(✓Upgrade(ol�Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No,�?,K c5 tC_4 F"FC 4 If f. Owner's Name,Address,and Tel.No.Z_G j1/�
Assessor's Map/Parcel Z —d-3 6
Installer's Name,Address,and Tel.No. 4.00,414 WSJ. Designer's Name,Address,and Tel.No.
c�u-�, �#.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) D i c ,Q
Date last inspected:
Agreement:
The undersigned agrees to ensdtnv
ion and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title ofmental Cod d not to place the system in operation until a Certificate of
Compliance has been issued by this Boa
Signed Date /-Z— 1
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued �p l
o
No. DI ! / n�
` 1 '' l � Feet (� '-'-"-
THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer: Y�L
j
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2ppYitation for Misoosal 6pstem Construction Permit
..� /✓
Application for a Permit to Construct( ) Repair(wUpgrade(/) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.�1K 5'�,c,q �'�s�6 7�''8,7.,. �' Owner's Name,Address,and Tel.No.t�
Assessor's Map/Parcel &r o '(
Installer's Name,Address,and Tel.No.Ctjoe 9,i(,4 C 6,7rr Designer's Name,Address,and Tel.No.
i
I)rpe of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures j
Design Flow(min.required) gpd, Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
2 1
�M
Date last inspected:
Agreement:
The undersigned agrees to ensdea
ion and maintenance of the afore described on-site sewage disposal system in
P Y
accordance with the provisions of Title 5mental Code at not to place the system in operation until a Certificate of
Compliance has been issued by this Boar
Signed DateZ f
4 Application Approved by (� Date
(Application Disapproved by Date
for the following reasons
Permit No. /� (�( Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
FHE COMMONWEALTH OF MASSACHUSETTS
� ?���~' `aC ,O� BARNSTABLE,MASSACHUSETTS
Certifirate of Compliance
THIS IS TO CERTIFY,that the O - ite Sewage Disposal system Constructed( ) Repaired( d� Upgraded
Abandoned( )by i i -
at � has been constructed in accordance
with the provisions of Title 5 and for Disposal System Construction Permit No. dated
Installer'LAI p ,, Ed;'f-T" Designer
#bedrooms Approved design flow gpd
The issuance of this permit shalln t be co strued as a guarantee that the system At-Mn- 'o designed.
Date / �/� Inspector
i
------------------------------------ ----------------------------—-----------------------------------------------------------------
No. t Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal .pstem/Construction permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at a�� ��� ,/ I l i� ,, 1 4L p
r
and as described in he 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.
1
1
Provided:Construction must be completed within three years of the date of this permit.
j Date ��i ( ( Approved by _�1� (� C� 4,,
I
i
1
No.-&&V r 017LI Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes /
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for ;Diopooal *r5tem Conotruction Permit
Application for a Permit to Construct( )Repair( )1 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
26 Sheaffer Rd. , Centerville John Zeller
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Ser.
P O Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms q Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting
of a D—box and 2 precast leach chambers with stone all around.
?�YK
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 Certifi-
cate of Compliance has been issued by this.Doar of Health.
Signed l Date ��R7 /
Application Approved by Date
Application Disapproved for the following reas s
Permit No. Date Issued
Feel&r
THE COMdd6J WEALTH O MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION —TOWN OF 6AANSTABL"ASSACHUSETTS Yes /
V
Application for Migw6al 6peum, Construction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No." Owner's Name,Address and Tel.No.
Assessor'?1fiap,49 gaffer Rd. , Centerville John Zeller �.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Ser.
P O Box 1089 Centerville
Type of Building:
Dwelling No.of Bedrooms Lot Size :` sq.. ft. Garbagj'Gniiinder( )
a Other Type of Building No.of�eFs4 s?— • / Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
San
Nature of Repairs or Alterations(Answer when applicable) ale--5 leaeh G* to I Go„silting
of a n 1hax a-d- 2 or-cast 1 -ach chambers. all around
Date last inspected: i f;
Agreement: t j
The undersign d 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 Kystem-in-operation,until a Certifi-
cate of Compliance has been issued by this Board of Healthy.'` �fi +
Signed 1 c Date 6
Application Approved by (" i / Date i
Application Disapproved or !e: ollowing reaso(`
4
t
Permit No. .,.._.Date Issued f`_11 f
------ ----L?----�' � ---
THE COMMONWEALTH!OF MASSACHUSETTS
1 C Jy
BARNSTABLE, MASSACHUSETTS
Zeller certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Dispp sal Syste I Constructed' epaired( X)Upgraded
Abandoned( )by W .,, s {
Ra n en S�rviC-2 ann
at 2_6 Shea f fer Rd. , Can rVi1 l e I has been constructed in accordance
with the provisions of Title 5 and the for Disposal Sys .in Construction Pe j t No. l dated�2 Q
Installer ., .� ,y: _,1 bbesi�f 9 � /�—Q /
The issuance of this permit shall not be constru d as a guarantee that the"system ill func n� s desig. -d.
Date r- , Inspector---------------------------------------
No. �74,0 Fee$r,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLEa MASSACHUSETTS
Zeller iof g 0 pnY� � � �te Congtruction Permit
�
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 26—Sheaf fer Rd. , Canto— - ----
and -
i
as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: Z�7 / Approved by _.y,,=�
8 3 _
1160"
NOTICE: This Folli Is To Be Used For the Repair Of Failed
4 Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
W i l l iota E. Robinson.S
.��Rtvreby ceriffy dw the application f; r disposal works
consuvetion per=stgtted by the dated 3 Z , concerning the
property Located at 26 Sheaffer Rd. , Centerville meemAofft
fouowing criteria:
• The failed system is Connected to a residential dwelling only. There are no commercial or Iwsiuess
uses with the dwelling.
• The soil is as CLASS I and the peroftfian rate is lew dean or equal w:5 mimues per inch
There ire no within 100 feet of the proposed sCpuc atistem —
There arc no private wells within 150 feet of the proposed septic s)smi
There is increase in Sow and/or Change in use:pwposod
• There no vanaaoes axpested or needed
• The of the pwpoaed l heiiitlr will Abe located less than five feet.above the
magi adjusted table elevation:lAdjust the groamdwater table using the Frimptor
when applicablel
If S.A S.will be hated with 250 feet,of any vegetated wetlands.the bottma of the proposed
leaching facility will�be located less than fourteen(141 feet above the t mvin»tn adjusted
groundwater table elevation.
Please complete the f ffie rimV
?►) Top of Gmund Sttdaoe Elevation(using GIS in mmaium) 7 0
B I G.W.Elevation +the MAX. liigb G.W.Adjustment
DIFFERENCE BETWEEN A and B
r
SIGNED: 1 DATE: `S v�7-0
(Sketch proposed Plan of system on back1-
q:health fetch:cm
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k, a s: ✓ � _ � ._ems:.: ,,,,:-..� x�.. - -.a,
..-, 4.._ ,r. .-. 'u-+.tv...•a.Ln iay. _ } Y ".Jl.t"@aIaZ+'Lr
-Y
- TOWN OF BARNSTABLE
LOCATION -a'fo SItF F�F2 jat� SEWAGE # v2coi i_J^y .
VILLAGE ASSESSOR'S MAP & LOT 17 Z -6 36
INSTALLER'S NAME &PHONE NO. Ro t'r15avy -5&rh1 T Ti-fi 7 7
SEPTIC.TANK CAPACITY
LEACHING FACILITY.: (type) _ Dieu WE((S (size) _4,( lays -a IF
NO. OF BEDROOMS
n/7 _
--------------
PERMITDATE: 3I�7 fo 1 COMPLIANCE DATE:_
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supp(yWell and Leaching Facility.(If any wells exist
on site or.within 200 feet of leaching'facility) Feet
f Edge:of Wetland and'Leaching Facility(If any wetlands,exist `
within 300 feet of leaching facility.)
Furnished by
Feet-
i�>'Yi. � i, i, it r \4k �, 1 1-.���-_S..Y4n.t+ay .i i:3k .� y�• .i ,y _r .. ',1 S i
L �
F
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Commonwealth of Massachusetts
ExecuWe Office of Environmental Affairs
Department of oc ���
Environmental Protection T ���FO
WIIIIam F.WeldGuarnor
L�
Ts.rua,,,y,EA
Da�minioner B.Struhs
03(o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: _ Address of Owner:
Date of Inspection: /6- - S'S of different)
Name of Inspector.., tit ic,
Company Name, Address and Telephone-,'umber:
CERTIFICATION STATt1 A
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
L--Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fa*
Inspector's Signature: Date: 4V)—1e) g
The System Inspector shall submit 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 P ES:
I 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 conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)SSG-1049 • Telephone(617)202-5500
Ranted on Recyded Pape+
•A
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):
broken pipe(s)are replaced
obstruction is removed
s� distribution box is levelled or replaced
The system require pumping more than four times a year due to bro n or obstructed pipe(s). The system will pass
inspection if(with a roval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
f
C] FURTHER EVALUATION IS REQUIRED BY Thk BOARD OF HEALT4
Conditions exist which require further eval lien by the 46ard of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
; I
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTHbETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AN1 SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet'of a borderin vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AN PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROT CT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septictank and soil absorption system d Is within 100 feet to a surface water supply or tributary to a
surface water supply.:
The wsten-, ha, a septic tank and soil absorption system an is within a Zone I of a public water supply well.
_ The system has a4eptic tank and soil absorption system and i within 50 feet of a private water supply well.
_ The system has�septic tank and soil absorption system and is ess than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria a volatile organic compounds indicates that the well is
free from poylution from that facility and the presence of ammon nitrogen and nitrate nitrogen is equal to or less than 5
PPm• � \
D] SYSTEM FAILS: /
I have determ i1jed that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this Bete oration is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure. ;`,
ackup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8/15/95) 2
h
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 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,b low the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I.of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flov. of system is 10,000 d or greater (Large System) and e system is a significant threat to public health and
g Y gP g g ) ) g P safety
and the environment because one or more of the following conditions a st:
_ 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 su ly
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%uch system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 51 rl and 6.00. Please consult the local regional office of the Department for further information.
(revised 6/15/95) 3
*ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ,�� SA f}e
Owner:
Date of Inspection:
Check if the following have been done:
./Pumping information was requested of the owner, occupant, and Board of Health.
L-_'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.
A1:1-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.
vThe system does not receive non-sanitary or industrial waste flow
vThe site was inspected for signs of breakout.
�II system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
,approximated by non-intrusive methods.
The facility ov�ner (and occupants, if different from ov�ner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: - G ,S6V 4 U Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: '33P gallons
Number of bedrooms: 3
Number of current residents: 1i
Garbage grinder (yes or no):LI/
Laundry connected to system (yes or no):—Y-
Seasonal use (yes or no): 41
Water meter readings, if available: %Cj 1" - 3 DOG J 1 `/'j - Z y U U d
Last date of occupancy: Q� �
COMMERCIAUINDUSTRIAL:
Type of a blishment:
Design flow: allons/day
Grease trap pre se es or no)_
Industrial Waste Holding resent: (yes or n _
Non-sanitary waste discharged to t system: (yes or no)_
Water meter readings, if av e:
Last date o cupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes or no)_
If yes, volume pumped J00 allons
Reason for pumping: Wl .
TYPE OFSYSTEM
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)
AJ!> S KI A rl oAJ 46ji
APPROXIMATE AGE of all components, date installed (if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) $
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grader
Material of construction: C-Eoncrete_metal _FRP other(explain)
Dimensions:
Sludge depth: I�
Distance from top of sludge to bottom of outlet tee or baffle: 1 q
Scum thickness: 41-A
Distance from top of scum to top of outlet tee or baffle: 41
Distance from bottom of scum to bottom of outlet tee or baffle: G
Comments:
(recommendation for pumping, condition of inlet and outlet tees or les, depth of liquid level in rely ion to outlet invert, st u ural
integrity, evidence of leakage, etc.)
o./Z
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: �oetefnetal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee e:
Distance from botto- ni nim t- hotto outlet tee or baffle:
Comments:
(recommendation for mping, condition of inlet and outlet tees or baffles, depth�ofliqui�elin relation to outlet invert, structural
integrity, �iden of leakaee etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr s: �� 5h4le-re2 AV .
Owner: U,
Date of Inspection: _is_
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concr a -metal—FRP—other(explain)
Dimensions: "
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, co ition of alarm and float switches, etc.)
DISTRIBUTION BOX:_ -
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
i
(note if level and distribution. i. equal, evidence of so.i„_ ca r)•over, evidence of leakage into or out of box, etc.(
PUMP CHAMBER:_
(locate on site plan) -
Pumps in working order.(yes or no) _
Comments:
(note condition of pump chamber, condition of pu appurtena etc.)
(revised 8/15/95) 7
1
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) '
If not determined to 1�2_p re nt, explain: ,¢
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comm : ( to condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) V eD
�iZ'
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 constru
Indication of groundwater.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil ' s of hydraulic failure, of ponding, condition of vegetation, etc.)
(revised 6/15/95) 8
r -
j' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S k A c CWx)4-v'
Owner:
Date of Inspection: —
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
PAO
G G
0
_ 2 C>
� C 3
G
DEPTH TO GROUNDWATER
Depth to groundwater: /5 feet y
method of determination r•approximation: e/
(revised 8/15/95) 9
TOWN OF BARNSTABLE
LGCF T—TON` a fo 5,hC- 4 F(ElL Roi4D SEWAGE # dOo I v f Viz/
VP't LAGE ASSESSOR'S MAP & LOT 7 2 -0 3 6
INSTALLER'S NAME&PHONE NO.Oo4,'JS6tti 3,-t*c 7 75-T 1-7 6
SEPTIC TANK CAPACITY t}oo U
LEACHING FACILITY: (type) AWE(Le, (size) a?(101i al
NO. OF4BEDROOMS— 3
BUILDER OR<jj�jD
PERMIT DATE: 312-7 I o COMPLIANCE DATE: 15ki 16 1
Separation Distance Between the:
Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
;;op site or within 200 feet of leaching facility) Feet
Edge',of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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