HomeMy WebLinkAbout0013 JOHNNY CAKE ROAD - Health 13 Johnny Cake Road, Centerville
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UPC 12634
No.2�LORq�, s
1�llaTtaa V!
No. 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplifation for MispoSaf *pstrm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Locat n A es r Lot No. �q ji� wner's Name,Address,and Tel.No.
Assessor'sMap/Parcel a L46 ap(o Tom✓ fi,�n��,ti
Installer's Name,Address,and Tel.No.,Sb Designer's Name,Address,and Tel.No:
Type of Building:.
Dwelling No.of Bedrooms o° Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A)I,� 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)
OLK-4 1 C
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 Heal
Signed Date f` 7/—7/
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. d 2.r— Date Issued
Fee
i
No. �" ? 1 3 lL��
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Uyis
01pplicatiDn for Disposal *pstem (Construction Permit
l�
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Comppenfs
Locaf on Address or Lot No. aP, wner's Name,Address,and Tel.No.
Assessor's Map/Parcel a l.�jgp(� )4y f
Installer's Name,Address,and Tel.No. ��'.�(�/ .�i�"�7 Designer's Name,Address,and Tel.No.
Y�v�.�.•, J ��'-" �„(- '!J,lot�n....
Type of Building: 1�y
Dwelling No.of Bedrboms t `t' f r 1 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) j�A- `gpd` Design flow provided }f;f /- gpd
Plan Date Number of sheets Revision Date
it Title
Size of Septic Tank Type of S.A.S.
Description of Soil
LNature of Repairs or Alterations(Answer when applicable) /7 e f-v cW��j
m,K -r�Jd
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 Heal -^1..•�^~""'� ""�`/'"
Signed Date /� 7/"71
Application Approved by Date ./ ) y
Application Disapproved by ,' Date
for the following reasons -
Permit No. 0 d 9 - S Date Issued C7/? t/ :Z
------------------
THE COMMONWEALTH OF MASSACHUSETTS
(_0jf0U( BARNSTABLE,MASSACHUSETTS , 1
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by
/ ..�--
---.at /3 .,/p}, yt�, Y C� �c- � � has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.20 /- dated C/b(7
� f
Installer '�G' e e�-+► �►s .� Designer
#bedrooms lov I A Approved design flow gP
d
The issuance of this permit shall of be construed as a guarantee that the system wilt.n as designed.
t
Date (>� Inspector `a � A� ,,.
- -- - --- - -2- / �i' -- - - -- - - --- -�-'-- -- ----------
` No. d a )11 J Fee :
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction hermit
Permission is hereby granted to Construct( ) Repair(f� Upgrade( ) Abandon( )
System located at
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 completed within three years of the date of this permit. r
Date E%J(�']! Approved by
'MESSORS MAP NO: D.1 0
No................-....... Fss ............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH L
C,-red- om-A.
-............................-----------OF.......................................
Appliration for UhipmFal Works Tnnitrnrtion �[amit
� Rom✓
Application is hereby made for a Permit to Construct ( ) or Repair ( 4-� an Individual Sewage Disposal
System at
--- Lo ation-Address or Lot No.
--...... ,..1--_._. : --------------------------------------------------- -------i.- ........s �.� f ,n..4� ........tea.................
Owner . Address .
WL ........ �` 1� l �............................. ........ Bsa-A.1.411Y.....Y-�p-....................................
Instal er r�
Type of Building Size Lot _. ��.®..Sq. feet
Dwelling—No. of Bedrooms-__--:2..................................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type e of Building
p„� yp _(�.__�S.____O5n,:e.1_ No. of persons.......... ............... Showers (V�— Cafeteria ( )
Ga Othe fixtures .........--•-••---•----------- ...
W Design Flow......... _ ______________________gallons per person per day. Total daily flow....._.. . .�---_.
................
WSeptic Tank—Liquid capacity:�®_.gallons Length....:4......... Width._'? Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.....:�....... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..........I.......... Diameter...........-1..... Depth below inlet................. Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1._. `.__-minutes per inch Depth of Test Pit.................... Depth to ground water_-___---___-------_--._.
IZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•---------------------------
Ra ._._
O Description of Soil•----••a 1 '. -- -:
�I •.........................
...........................
----•--- ----------- - ...--------------------------------------....-----------------------------------------------------•----
U Nature o epair Alterations—Answer when applicable. 10�c. ------------- & �e
a
-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T:LE
p 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.
Sied.. . --- • `--------------------------- / -- -••-----•-
to
Application Approved By.................. -�-.-. ............................................... 7
- ----ta
te...-------••--
Application Disapproved for the f ollowin reasons--------------------------------•----•------------------•----------------------------.
-----------------------•---------•-•---•---------------------•-----------------------------------------------•------------- ------------.....
Date
PermitNo......................................................... Issued.......................................................
Date
a 41 O
No...� I b`t b.__.. 116
FEs. .. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ . ..............O F.........................................................................................
Appliratiun for Disposal Works Tunotrurtion jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( v) an Individual Sewage Disposal
System at:
I.: ....__ .1-1.&•t•-...........('11-k-C--- S ' 3t� ! { luny f -.................--
Location-Address or Lot No.
��a.._.. - ._... •........................................................ .......i ------------.X. :..._.....f� l t_.�.._...........
1 Owner / 7Address
W ........... -- ------LA?.......... W /"O 1. ........?.�__
>'" -•-----------------------•----•------
Instalier Address
Type of Building Size Loth_AJt_00_U...Sq. feet
Dwelling—No. of Bedrooms... ..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building Rf'-_e.....O.W.,2l No. of persons.........5................ Showers Cafeteria ( )
Otherfixtures .-----------•-- •--•-•-•--•-.......-•--••••-•-•.......---•--......--••-••---------•-----•-•-•••-••--••--•-•-••-•-•----•---•-----•••-•----•-----•--•--
Design Flow........ V-•-------------- �••-•-• ••---
W gallons per person per day. Total daily flow____._.___. 3 - gallons.
W Septic Tank—Liquid capacity :..gallons Length_..A......... Width.... -___-_--- Diameter----------------
Depth................
x Disposal Trench—No. .................... Width.....:Y��...... Total Length.................... Total leaching area_-_____---•••------sq. ft.
Seepage Pit No---------1---------I Diameter...........1...... Depth below inlet...... :.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test.Pit No. 1..4.a`____.minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ir, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----•---••------------------------------•----------------....-•--•-•--_.
Description of Soil.......� 1--•---•. ...............................---- �'
---------•----•-•------------•----------------•-------•-•----•------------•-----------
UW ..----•----•---------------------------•-......---------- --• ......
Nature o epair Alterations—Answer when applicable...........P.vUv__._ c_,__........................ ±' l�s-jJ
--------•P..............................-.............................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T K
p �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.
Sig ...........................................
- rs_�� t ate ...
ed. - - ...... ._t .................................
._....._
Application Approved B
l! I
Date
Application Disapproved for the following reasons---------------------••-•---••--•----.....--------------•---------•-------------••-----------------......-•-•---•
--------•-•------------------•-----•-----•------------------•-----------...--•-•----------...-------•---------••-----------•--•----------•-----.....---•-••••-•••-•..................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--......� ...............OF.........IV ........... .....................................
Tlertif iratr of Tourph anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (s }
C--. #:
Installer
has been installed in accordance with the provisions of T i T IE j of The State Sanitary Code de ribed in the
application for Disposal Works Construction Permit Nod-{?.-.�L'_ _7.............. dated--------I,.......
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANT E THAT THE
SYSTEM WILL FUNCTION S TiSFACTORY.
DATE......................1. •--�-- -•------••-----•------- Inspector.••. �-- ..............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....•••••.. •--
No .............. FEE........................
Disposal Trkp Tono�rttrfioat autit
Permission is hereby granted------------ �.__� ----------------------'---sn t----'-41n----•......
•---------------------------------
..---•-----•---
to Construct ( ) or Repair (1IQ an Individual Sewage Disposal System
atNO. ----••----••••-•----•-••-•-••••- a s�i.�. to�� - -t-�--1 �........................•• ...
Street v{6 -,10q j
as shown on the application for Disposal Works Construction Permit No..................... Dated....
___._:..........................
t-. P
..........-••-•-..0.... ------4---
f Board of-le th
DATE---------•- -----•......--_� .>
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
l
Commonwealth of Massachusetts `s
Executive Office of Envirolunental Afairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 John Grad
lug D.E.P. Title V Septic Inspector
a '�$I�Teaticket, lVlA"02 `36
WILLIAM F.WELD '(508)564-6813
Governor
ARGEO PAUL CELLUCCI O
PART A
Lt.Governor .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM OcT ��
? D
CERTIFICATION �Oy�f� C7 0 7 W
Property Address: 13 Johnny Cake Rd.Centerville Address of Owner:
Date of Inspection: 10/14/97 (If different) e9
Name of Inspector: John Graci Nancy Eaton
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name, Address and Telephone Number:
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:
x Passes This Inspection Is based on criteria dented In Title V
— Conditionally Passes code 310CMR16.303.Ny findings are of how the system is
performing at the time of the Inspection.My inspection does
Nee/Ubmit
rth r Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
Fall septic system and any of Its components useful life.
Inspector's Signature: /�� Date: 10124197
The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The systern,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, 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 exhItration, 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 0Q7)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10114197
_ Sew.eae backuu or.hreakout or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to 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 leveled 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] FURTHER 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 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 of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
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 in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge of,pondhig of effluent(o(lie 9ufftlCe of 1110 UlWild Of 31.11'fdC:e W8(@t5 tall@ to till OV@1lOddCld 01 C'10ggdd
cesspool.
SAS is in hydraulic failure.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10114197
D]SYSTEM FAILS(continued)
Yes, No
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).
Numbers 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 1 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:
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:
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 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 04121)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10r14197
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with NIA.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System, have been located on the site.
x 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.
x 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)]15.302(3)(b)]
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10114197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g.p.d./bedroom for S.A.S.
Number of bedrooms: 2
Number of Current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no)-I o
Water meter readings,if available: nra
Last date of occupancy: n1a
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last year.
System pumped as part of inspection:(yes or no)Yes
If yes,volume pumped: 1800 gallons
Reason for pumping: Maintenance
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions 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:
APPROXIMATE AGE of all components, date installed(if known)and source Information:
Origlnol36 years with New pft Installed In 1989
Sewage odors detected when arriving at the site: (yes or no) No
(revlaed 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10114197
SEPTIC TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Na
Sludge depth:rda
Distance from top of sludge to bottom of outlet tee or baffle: rda
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance form bottom of scum to bottom of outlet tee or baffle: Na
How dimensions were determined: Measured
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.)
Na
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rva
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: ria
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: z'
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction IineSo-
Diameter: 4"
Q,mments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10n4I97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: We
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: We
Capacity: rVa gallons
Design flow: rva gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Ma
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yea
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(rsvlaed 04127)97)
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Johnny Cake Rd.Centerville
Owner: Nancy Eaton
Date of Inspection:10f14197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers, number:rue
leaching galleries, number: nla
leaching trenches, number,length: rue
leaching fields, number,dimensions:nla
overflow cesspool, number:e•xe'block
Alternate system: rda Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pits are structurally sound and functioning properly.The leach pit C was empty.
CESSPOOLS:x
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: 3"
Depth of solids layer: 1"
Depth of scum layer: 3"
Dimensions of cesspool: 6IX61
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
nfa
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Main cesspool and all components are structurally sound.Recommend pumping system every one year for maintenance.
PRIVY:_
(locate on site plan)
Materials of construction: nla Dimensions: Na
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nla
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
13 Johnny Cake Rd.Centerville
Nancy Eaton
101'1097
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
LED
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4A aL
�a 31
AC �b
VC
(revised0a27RJ7) Tape ! of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
13 Johnny Cake Rd.Centerville
Nancy Eaton
10114197
Depth of groundwater �z
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 Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
completed)
Describe in your own words how you established the High Groundwater Elevation.(MUST be p leted
)
USGS Maps and Charts
(revised 04)27197) sage 10 o1 10
L C,
T TOWN OF BARNSTABLE yG
LOCATION (� ke SEWAGE # 2
4
VILLAG4ly ASSESSOR'S MAP LO
INSTALLER'S NAME & PHONE NO. (2 �i ►r��yj j °���
SEPTIC TANK CAPACITY S.r_�
LEACHING FACILITY:(type) i�i p Al A (size) 00 ("4
NO. OF BEDROOMS J PRIVATE WELL PUBLIC WATER
BUILDER OR OWNER to , L ATo
DATE PERMIT ISSUED: /(- /
DATE COMPLIANCE ISSUED: 10 47
VARIANCE GRANTED: Yes No
1
'' 1 ��
j �
� __.
LC3T a2TOWN OF BARNSTABLE
LOCATION v SEWAGE
VILLAG ASSESSOR'S MAP LO
INSTALLER'S NAME & PHONE NO. 6k,,4�ihl
SEPTIC TANK CAPACITY S�
LEACHING FACILITY:(type) �a�P A T (size) /G d O
NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER
BUILDER OR OWNER ,� Z ,pno F
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED: 10
VARIANCE GRANTED: Yes No ffi
I
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