Loading...
HomeMy WebLinkAbout0049 SHEAFFER ROAD - Health 49 SHEAFFER ROAD_, CENTERVILLE A= 172 074 - I 1 llll =J�QEcvccfoc m � �H UPC 12543 N0. 63LOR NASTINQS.NIN � 4 TOWN OF BARNSTABLE SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL,,'�J m Of317,0' INSTALLER'S NAME&PHONE NO.'.-�/* SEPTIC TANK CAPACITY,16"'e-m- LEACHING FACILITY:(type) (size) / V eZ I'�eZ NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: 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 a t � t No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for, tisposai 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot Noy9 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. lT��i �ov/t 7 7 f' fir' Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4�OC' 46'-f+ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 o gpd Design flow provided O gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 4.0 Nature of Repairs or Alterations(Answer when applicable) .P d-Af Or-'V,4/,0' 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 by this Board of ealth. J� S' e Date Application Approved by Date 7 ol Application Disapproved by Date for the following reasons Permit No. /3 — 'I)-u 7:5 Date Issued V' j No: /J 4 Fee /© THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k A , `►, ma. Yes PUBLIC HEALTH DIVISON - T VVN OF BARNSTABLE, MASSACHUSETTS ltJYication for ='1, Ili sat Spstem Construction Vermit Application for a Permit to Construct( ) RepJC )' Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot Noy9 fJ /�/C �� Owner's Name,Address,and Tel.No. \ Assessor's Map/Parcel /1 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms i Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ;e' �f'. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) *® gpd Design flow provided gpd t' a Plan Date Amber of sheets / Revision Date •s Title Size of Septic Tank- Type of S.A.S. Descriptttion-of SOiI Ir4"o- t ,c Nature of Repairs or Alterations(Answer when applicable) J'c�` 4;;� Date last inspected: !f. 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 by this Board o ealth. Si e Date 1> Application Approved by Date 7 64`/ Application Disapproved by �•t Date for the following reasons �. Permit No. J Date Issued 61 ------------------------------------------- ------------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance \ THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( � Upgraded( ) Abandoned q( )by �' e� GEy/�has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nq�/3 0 y� dated A�L Installer 07,.,w e;6'.9 r Designer `l4 & /*r,,A o X- DeJ' #bedrooms _5r Approved desi n flow_-, A,0 gpd The issuance of this pe i s 'll no e co strued as a guarantee that the systemY ction as designed. Date Inspector GJ '� 3 ------------------------------------------------------------------- tl - --------------- No. C'-\-\ �5 Fee � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposat *pstem Construction �ermit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon �� ( ) System located at 15;/9 �✓ /'����� �''C <4�'^005- 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. Provided:Construction must be •ompleteld within three years of the date of this permit. Date � � `/ Approved by\ Jul 0213 09:26p Colleen Mason 508-833-2177 p.1 Town of Barnstable regulatory Services h� o� } Thomas F.Ceiler,Dirbetor • sn�vsra�aF,s. a Public Health Division A�� Thomas McKean,Director 200 Main Street,Hyannis,TVIA 02601 Office:_50"62-4644 =Fix: 508-7.90-63C4 Installer&Desigaer Certification Form Date.- V -41 Zo1� Designer: C) Installer:-:; w1 L&tCFQF Address: . �J "� `�► 1 Address. ��6 Vq 4rt 7 2 Zo l ?J' .. 71k was issued a pen#.to install a (da e) (instaUd) septic system at l based on a design drawn by (address) (designer) _zi'.eerfify that the septic system referenced above was installed sst -ania-au. accor�g'to e design, which may include ntinoi approved-Ranges such as iateraa.zelocatioaa of the dWribution box and7or septic tank.. I certify that the septic system reterne . above was ins±aRed wit$°zna cbanges`(i;e, greater t 10' lateral relocaf66-of the SAS or-any vertical'i� ocatign o€anY comppn t of the septic_system)but iR abwrdance with State&L•ocal:Regdlations. Plan reyisiQn or certified as-bi desigQe to follaw = c� 3 uD (Instal]er's SiNatn3re) `164RS�N, a o:V66 <� �iTrAR PL s Signature) ( =! er's Slap Here) PLEASE RETURN TO BARNS [' : 'IIBYAC:HEALTH DIVJSIGN._CF.WrMCALTE OP'-C4i4�IPl�3Al CE. .' l�t�'T: v-- UED . -BOTH!T�[IS�1�4RM RUB. :4CARD ARE RECENED -IT.W SOON: THANK Yo III: - = Q;ffeal&geptidDesipn T Certification:For.:, Town of]Barnstable P#106 Department of Regulatory Services RAMST"M : Public Health Division R >� Date s639 �� 200 Main Street,Hyannis MA 02601 ti Date-Sc heduled Time l 0 Fee Pd. So Suitability Assessment for Sewage Disposal Performed By: Witnessed By: � Location Address LOCATION& GENERAL INFORMATION �9 S'��w' Owner's Name Address V/M Assessor's Map/Parcel: ��a 1 04 Engineer's Name NEW CONSTRUCTION REPAIR � Telephone# Land Use Slopes M Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line _ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) �l Ln W C/ Parps material(g ologic) Depth to Bedrock DeO to Groundwatte"r-. Standing Water in Hole: 1f 6_4 Weeping from Pit Face s U') EstCi'rtated Seasonil:"'i' h Groundwater C:) N iftERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: ia, Depth to soil mottles: Depth to weeping from side of obs.hole: ln. ft. Index Well# Reading Date: Index Well level in, Groundwater AdjustmentAdj,factor- Adj.Groundwater Laves PERCOLATION TEST We Time, Observation Hole# _L Time at h" Depth of Pere Time at 6" Start Pre-soak Time @ / i. Time(9"•6") End Pre-soak a Rate Min./Inch �) UV AS �W 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. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIWERCFORM-DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Sto,ics,Boulders. on istenc 4N.Craven 19 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil r Surface(in.) (USDA) (Munsell) Mottling (Structure,Sto.. .Boulders. Consi tenc ,%Gnivel) 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 Soll Other Surface(in.) (USDA)' (Munsell) Mottling (Structure,Stones,Boulders. Consistency, ,t Flood Insurance Rate Map: T Above 500 year flood boundary No Yes Within 500 year boundary No / Yes Within 100 year flood boundary No °� Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious m terial exist in all areas observed.throughout the area proposed for the soil absorption system? " 4eP2 If not,what is the depth of naturally occurring pervious material? � Certification I certify that on W (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was performed by me consistent with the required training,exper' e and a er nc described in 310 CMR 15.017. Signature Date Q:1S.EPTiC\PERCFORM.DOC tE `G TOWN OF BARNSTABLE LC34 ri 71ON f S He A FFeR R d SEWAGE # VILLAGE G c'Al YC R 1/!L G P ASSESSOR'S MAP & LOT ),- INSTALLER'S NAME & PHONE NO. 4 g c 01A,c4eR r 5 0 v SEPTIC TANK CAPACITY X p o Z> LEACHING FACILITY:(type) /"! f (size) !• p yd NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Ll DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:f-aI VARIANCE GRANTED: Yes No V-� S=. �.. �'. � �' � � .,` � G� � �-� � s6 ' � � �, , 0 ASSSESSORSW NO' "� No. �••' G PARCELN� k . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYtcatton for Mtoozat *rgtem Comgtrxt' Application is hereby made for a Permit to Construct( )or Repair X)an On-site Se�age Disposal System at: s � � Location Address °t No. 1/n'/ Owner's Name,Address and Tel.No. 11 e p. 4ct F ` c.2w IJA1 5. W4. G. SL._ Installer's Name,Address,and Tel.No. f Designer's Name,Address and Tel.No. (00S` 0 XY*A-ShP -m u Type of Building: Dwelling No.of Bedrooms 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 Description of Soil I � Nature of Repairs or Alterations wer when applicable) Date last inspected: 1301), 199 N` 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 'ss ed by thisBoard of Health. Signed 'c' Date J. Application Approved by w/L Application Disapproved for the following reasons Permit No. !— Date Issued NOV - 13 e I C1 S.S ———————————----————————————————————— r' THE COMMONWEALTH OF MASSACHUSETTS j PURL-LC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for Mizpogar *pgtem ttCongtr t'. n er v- q0tvf �7 Application is hereby made for a Permit to Construct( )or Repair jK)an On-site Sewage Disposal System at:l E, Location Address or Lot No. Owner's Name,Address and Tel.No. CL Installer's Name,Address,and Tel.No. ( Designer's Name,Address and Tel.No. vo Type of Building: " Dwelling No.of Bedrooms 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 Description of Soil s V-1-1111, v-4 1 D r Nature of Repairs or Alterations saver when applicable) Date last inspected: U01), V3 7 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in acc \dance 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 bee ss ed by th's Board of Health. Signed r 1� Date Iy D J° 11 , Application Appro�d by _ /.y Application Disapproved for the following reasons Permit No. � !- Date Issued Nov . /3 C1 S.S THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance - 1� IS IS TO CERTIF that the On-site lSewage isposal System ins alled( or re ired/replac d( )on s G1l A by for 4 -E G. ; C_ r S nti, as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated P O V ° 3 1 q 7Y Use of this system is conditioned on compliance with the provisions set forth bel r No. �Y✓ / / M1 ` Fee D O THE COMMONWEALTH OF MASSACHUSETTS r, PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS T _ , Mi' 5al *pttem Construction Permit \ K t Permission is hereby granted tor1rj to construct( )repair(/L,).aTr'On-site Sewage System located at P lnek and 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. All construction must be completed within two years of the date below Date: N` 9 V 1"�, ' `�S Approve . y ' I a , r jt 1�13 CERTIFIED SEPTIC SYSTEM REPORT fi6W LOCATION 49 SHEAFFER RD . (' NOV CENTERVILLE, MA cfMAP 172 PARCEL 074 LOT 148 3 1990 PREPARED FOR S �+ SELLER MR. & MRS . FRANCIS SHEA 49 AMBERWOOD DR. WINCHESTER, MA 01890 BUYER MR. & MRS . BERNARD ZIEMAN P .O . BOX 325 OSTERVILLE, MA 02655 PREPARED BY HILLIARD HILLER, JR. P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 Commonweafth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld CsotAmor Trudy Coxe srrcr.tuy,EOEA David B. Struhs cor+im�.w�er SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: y9 Sh'G9F/�/1 RO GSA,,rE•ed- G1" -`Address of Owner: Date of Inspection: (If different) />Qsre.Q Name of Inspector: N/G1-/"W /N/GG, oe Company Name, Address and Telephone Number: Pp foX aSa G,c1"re,rrr//6GE Ai/9 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 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: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: / Date: 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 ano copies sent to the Buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Aj SYSTEM PASSES: _/ 1 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. 8] 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. �f 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) One Winter Street • Boston,Massachusetts 02108 • FAX(617)SW1049 • Telephone(617)292-55M i•� Printed on Recyded Paper • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: I�i�i�i �/�/�/✓C/d S/��iA Date of Inspection: BJ 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 Y� 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 Cl FURTHER EVALUATION 15 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 protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: + _ 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 WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The systen, has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.. Backup of 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: s 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 below 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 flow of system is 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: 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 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S�IyA/G�� /�� C�c•�r �//max �A , Owner: All,/I CI_5 Date of Inspection: Check if the following have been done: l—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 a5 part of this inspection. vAs 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. _4,.-The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. vAll system components, excluding the Soil Absorption System, have been located on the site. �1 he 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. &4he facility o,tinc, (a.-' occupants, if differcnt frorn owne-) were provided \vith 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: Ro f*,e Owner: h/i.1 Ae".fv`c Date of Inspection: /X; t FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents:) Garbage grinder(yes or no): /dD Laundry connected to system (yes or no):-f r Seasonal use (yes or no): Water meter readings, if available: oaJ Ci9L /�17 3 73�yU0 Cs/9G Last date of occupancy: COMM ERCIAL/INDUSTR[AL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) VO If yes, volume pumped tzallons 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: d- "�" GoJX //a shy y � .�sil �jy-0�07 Sewage odors detected when arriving at the site: (yes or no) AL'47 (revised 8/15/95) S i s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: ol SEPTIC TANK: Zl� (locate on site plan) Depth below grade:,( Material,of construction: L/concrete _metal _FRP—other(explain) Dimensions: ' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.) 7iFA-' ' // E /4/.1G O 411 s5A� G 5�/diG F G v?' i1 "�JG'c /x-- T6L"—e GREASE TRAP:_ (locate on site plan) Depth below- grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of 5rum t- bottom of ou?iet tee of b2me: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level injelation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: G�,C- rA-�e,-l"IC— /� Owner: H�iy �% .cam.-fr�� Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP--other(explain) Dimensions: Capacity: eallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: L/ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if le e! and d:strb tier. i. equ�!, evidence of so!id< carryover, 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 pumps and appurtenances, etc.) (revised 8115195) 7 Y • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L/"1 J`�E�9FF��C /�o G�.c/l/i/1 v/GGZ AA Owner: "KA kxA4'&C S 5/t,� "!1 ' Fil 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 be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) �/7- -s- r i od��o Goa 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. 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.) J 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ll-!�P Owner: ^OA F/�ilvcis Sf/�f',4 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i W . w 6,09446 C DEPTH TO GROUNDWATER Depth to groundwater: /S t feet method of determination or approximation: 941/ 61wlfee G✓5 Sf x✓S TffL E G.��Tie,y /li i�y.± �;� To 44 7,2 Tfrc A/T is is67' oEVf? 7'r/2 4>&L&Xv g u-,,rr✓4 TA,j'e,,r Tu g /C-t 4 a s'Oeve.-3 7-r2 7a 37 -9.3= /S,b,? (revised. 8/15/95) 9 NOtES: ASSESSORS HAP : 17 _ IT ST I-IOLL- LAGS PARCEL: �� _ _ _ - 1) Tile installation shall comply witli Tille V tand 'f"wit of/ J/j aid of FLOOD ZOIIE: � � SOIL EVALUA1Ufl : 1lealth Rqulations. , . I p J IlE1=EIlEIICE: � � t,�� �,--� •�pi.� 2) I Itc, uislull�l•shall vcnl� lh� location of ulilili�s sewer ulvuls quid sc ilic i DATE: cutu ponents rtior to installation and sellin ; base elevations. ?COS qq�� rEltcoLA1 I uIJ ItA l E: �- Vvk t I t 1 1 1 �U 3) All gravity septic piping to be d inch Sch ,I0 PVC at 1/8" per loot. 'l'lte litst two lbet out ol'the d-box to the leaching shall be level. i --- -- — - -----^ —'" -- 1 I(- I 11I-2 �I) 'phis plan is i'ot to be utilized fur property line deter"►ivation nor any other ptapose other than, the proposed system iuslallalion. b'll F�� l0 ' � l0 `2 1 5) All septic co"'pone"ts "'list meet'l'ide V specilicalious. ---�— � �'�p tlrY � C) Packing shall not be constructed over I110 septic components. / 7) The property is bounded by property corners and property lilies. a 8 'l'he rroperty owner shtall review design eot►sideralio"s to approve of total LOCA I I 0I1 IvIAI'C ► ,SJ 67 3 7 design flow and number of bedmouas to be considered lur design. Receipt i of payment Ibr the plan and installation based oil the plan shall be deemed j1pproval ol•the design flow by the owner. 1 I CG W 5 ^! j 9) 'rlte existing leaching or cesspools shall be pumped and filled with ntalerial )er'l'itle V ubandonntent procedures. 'those within the proposed SAS shall ° I� 1UfV7f`� 104fl_7 � I be re'uoved along with con(aauinated soil and replaced with clean scud per y 0f���j ✓ Title V specs. % I?� ', a � �J l0 10)System components to be 10 feel lion► water lice. Sewer lines crossing the water line shall be sleeved with 4 inch SCl 1 ,I11 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service e is to be sleeved as ali'remenlioned and maintained in,) lace. L11T I C SYSTEM DES I Gil ' S line. lhehn I I I) if a ga'buge grinder exists it is lu be removed and is the responsibility of th owner to ensure such. i FLOW ESTIMATE 12)'Fhe installer is to lake caution in,excavalion t"ound tile 'as line il•such exists. c UEUIIUUhfS AT GAL/UAY/EfEUIiOOIJ - (3AL/DAY �13)'Fhe installer sha1I.M-ify the location, quanlily and elevation of the sewer lines exiting the dwelling jarictr to [lie installation. Il)'I lais plan is representative only that it system can lit on it property n'ecling SE-VT I C TANK / Title V requirciuents. L,;V GAL/DAY x 2 DAYS 060 GAL / S TIC TAI M r• USE �� GALLOIJ Er, CL­rAQ40WTT ?FTO ;. Sk►"1-C All�ulll�'1"1 U(T-SY�`f Ei�l �.� � '•- �j � �-1Dt�-I� lA-2�VU-tom - \ Z ,-7 % /bj52- OFfl�q S I DE AREA: �� �- >C ���H ss9 � 1 t 1 _ J �..�M,► -- \ UUTTOM AREA: �X C�� 7 Z30��� � DAVID �y ` D CIAO M. MASON mm r 0 No.1066 O c� S LC�I' 101� �GIS SLf l� I C SYS-I-L-M.' 11V-j M�kl . t ca' q`a to o o i;—=,1. till I l� _ Q�[tli�1, r. UAL 4MVNW�_ 14 pili \'(01,_3o SEPTIC TArllc ��_I_'Lz' c ,u� tr ? 5- ----_ X0 6191 ------- S I �I-E MAD S LVM- [ PLAN LOCA•I' 101,1 : V1• PREPARLD FUZZ :;j mA P 1 ° t scALE : l 7 a DAY I D 13 . 1JASO11,q4;I DATE: t Z� ° D13C EI1V I BQ111YIE11TAL UL� I CIJS I::AST SANDWICH . MA pA-1E { IIL"AL111 AGE11f ( 50f) J 833- 2 177 Z I