HomeMy WebLinkAbout0100 DUNN'S POND ROAD - Health 100 Dunn Pond Road
Hyannis
/ A=270-015
9
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TOWN OF BARNSTABLE
LOCATION 160- i9 f.t3 ,Dynas I-3nd SEWAGE# Z6 -
VILLAG ASSESSOR'S MAP & LOT 170 -o/5
INSTALLER'S NAME&PHONE NO. /?7//?7 D LlknC Se,011C
SEPTIC TANK CAPACITY 45bo 6z9l
LEACHING FACILITY: (type) (a9 /a"PrrChPs (size)-�S6/x
NO.OF BEDROOMS
BUILDER OR OWNER
F xPERMrrDATE: !-9 9; COMPLIANCE DATE:
�t
V`,Separation Distance Between the: _
Maximum Adjusted Groundwater Table and 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 #
r.
a
00
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TM
c
e
-e `Q
z No. p';! Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprtcatfon for Migonl 6potem Construction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.�� ��5�� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel01
�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
e✓ b�r- aoa�
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 '� gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ----Type of S.A.S. 'Ty n,%.ZJA-es
Description of Soil
Nature of Re airs or Alterations(Answer when ap licable) =U -sue AA1 1'S b0 Sra l L -T1—e_
TWD _7 � e
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 oar e lth.
Signed Date /c2-3Ole
--
Application Approved by �.J Date
Application Disapproved for the following reasons
LX
Permit No. — Date Issued
-� 10
t Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
f Yes
PUBLIC HEALTH DIVISION - TOWN OF'`BARNSTABLES MASSACHUSETTS
ZippYication for Xh5po.5al 6potem Construction Ve'rFmit
Application for a Permit to Construct( )Repair(Apgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.160 &-eytys � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel. OVWAS
Installers 7Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7
�/�erg/�(?�✓`�-s �'D�19�r�/Y
,Ty
pe 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' gallons per day. Calculated daily flow �� gallons.-
Plan-Date Number of sheets Revision Date
Title '
Size of Septic Tank Type of S.A.S. . -TV
Description of Soil .
Nature of Repairs or Alterations(Answer when applicable) Tth-ST A t-� 1'S 6(2 Sr/li l -T eq N C�'
T(�fJO
Date last inspected:
kAgreement:
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 Board a lth.
Signed / Date -2.146
Application Approved by Date '
` Application Disapproved for the following reasons
Permit No. '-' ,Date Issued
THE COMMONWEALTH OF MASSACHUSETTS ,
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal S s Constructe )Repaired (1/Upgraded( )
Abandoned( )by N\'t (�-r 14 D�P, �(�\ ��
at A D h eEn constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will funct4 n as designed.
Date I - 37 Inspector °
— — -- ----- -----------------------1
No. _ —— —— d .r L/1`./ Fee
THE COMMONWEALTH OF MASSACHUSETTS
P,UBLIC HEALTH DIVISION - BAR.NSTABLE., MASSACHUSETTS
nigo!6al *p!5tem Construction Vermit
Permission is hereby granted to Construct( )Repair( Upgrade( Abandon( )
System located at
L
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. .�,,� /
Provided: Constructs n m st be completed within three years of the date of thi elms
Date: Approved by / ! .
NOTICE:_This Form is to be Used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated /�211—12& concerning the
property located at Zoo 0✓��'� � � meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: Z9
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a'sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
I
j xert
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µ TOWN OF BARNSTABLE
LOCATION &-a i9 f�3 .��n/u J�n� �t� SEWAGE #
VII.EAGE /�S/,4A/I!S ASSESSOR'S MAP& LOT Ala ��
INSTALLER'S NAME dt PHONE NO. -/1�/1�
SEPTtC:;TANK CAPACITY �Sbo 6:9l +
LEACHING FACILITY: (type)
NO.OF,$EDROOMS
BUILDER OR OWNER
PERMIT-.DATE: I -9 b COMPLIANCE DATE:
:Separation Distance Between the:
Max iium Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private,Water Supply.Well and Leaching Facility (If any wells exist
on;siteor within 200 feet of leaching facility) Feet
Edge;of'itland.and Leaching Facility(If any wetlands exist
wiiW 300 feet of leaching facility) Feet
Fnrni3hed by
I�e�R o F Nouse
A
0
0
d
0NI �`��0�?Y��..TH OF ASS1A.C 111£TSETI'S �
p
EXECUTIVE OFFICE OF E,,%-ITRONMEi1 iikL AIRS
DEPARTMENT OF 'ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A "
CERTIFICATION
Property Address: 100, )1 4S rJC f� 41 j
i /
Owner's Name:
Owner's Address:
tag
Date of1Inspection• �
.. ,...-s
Name of Inspector: lea print) _ ! i
Company Nam__• tit Me 0.46/9075�'t,Ta�K-S
Mailing Address: r-'ii •
Telephone Number: .!�W
--ass--26t>8 ref;
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my a
training and experience in the proper function and maintenance of on site sewage disposal systems.I am DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
� Fails &��� V
Inspector's Signature: �s<� Date: 4o� 0_4f
The system inspector shall submit a copy of this inspection report to the Approving Authority(Boar4"of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of I0,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address ltow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Norm 6/152000 page I
Page 2 of l 1
r ati
OFFICIAL.INSPECTION PO -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Oo 2
4k 401 i55 _
Owner: rer j'Gce, M
Date of Inspection:
Inspection Summary: Check. AAC,D or E/ALWAYS complete all of Section D
A. System Passes:
I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the and of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following " ements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the se c tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfilb ation or failure is imminent:.System will pass inspection if the
existing tank is replaced with a complying septic tank as" roved by the Board of Health.
*A metal septic tank will pass inspection if it is struc y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ble.
ND explain:
Observation of sewage backup or reek out or high static water level in the distribution box due to broken or
obstructed pipes)or due to a broken, ed or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)anesd
obstructim issamoved
distribution box is Ieveled nr replaced
ND explain:
The system re d pumping more than 4 times a year due to broken or obstructed pipes).The sygem Will
pass inspection if th approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Pame 3 o€11
OFFICIAL, INSPECTION FORM e NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 0 V'1 C �a
Owner—
Date of Inspection: ,S �r�/06
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 ' e system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 15.303(l)(b)that the
system is not functioning in a manner which will protect public health,sa _ 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 and or a salt marsh
2. System will fail unless the Board of Health(a Public Water Supplier,if any)determines that the
system is functioning in a manner that protects a public health,safety and environment:
_ The system has a septic lank and soi sorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s ce water supply.
_ The system has a septic tank d SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a s tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply Il**.Method used to determine distance
**This system p s if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and vo the organic compounds indicates that the well is free from pollution from that facility and
the presence f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure Grit 'a are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
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page 4 of 11
OFFICIAL INSPECTION FOAM NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DffiPOSALSYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: 0 v
f i
Owner: f�1 JYt�i
Date of Inspection Sow
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day Bow
- L 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 SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone l 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.]This system passes if the well water analysis,
performed at a DEP certified taboratory,for califerm bacteria and volatile organic,compamds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
�® (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CNM 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow 10,000 gpd to 15,000
l'Pd- : .
You must indicate either°yes"or"no"to eich of the following:
(The following criteria apply to large systems in addition to the critc above)
yes no
the system is within 400 feet of a surface g water supply
_ the s/7theetithin 200 feet of butary to a surface drinking water supply
the socated in a trogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zonblic supply wellIf you have anes"to any question in Section E the system is considered a signii;cant threat,or answered
"yes"in Sectithe large system has failed.The owner or operator of any large system considered asignificant thrSection E or failed under Section D shall upgrade the system in accordancewith 310 C1vIR15.304.The ser should contact the appropriate regional office of the Department
4
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
(� CIIECKEIST
Property Address: /b0 j'-)V"5 RAS
(Owner: ri _
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
o—� — Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks'
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
` Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
i Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
_
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CNM 15.302(3)(b)]
5
Pate 6 of`_1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address- .Ydn6 O LAC
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): $� Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): SS y
Number of current residents: 6
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): 0 [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no): I
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):nvw�
Last date of occupancy:
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.20 °Pd
Basis of design flow(seats/person ft,etc_):
Grease trap present(yes orno) _
industrial waste holding to present(yes or no):
Non-sanitary wasted
ged to the Title 5 system(yes or no):_
Water meter reading if available:
Last date of occu cy/use:
OTIIER(d cribe):
GENERAL INFORMATION
Pumping Records
i
Source of information:
Was system pumped as part of the inspection(yes or no):I
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
A Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
-
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMj�INFORMATION(continued)
Property Address: /do JRv&%6 F&J KFJ�
r,vtnks
Owner: Fe r to
Date of Inspectios'T�_a��{
BUILDING SEWER(locate on site plan) .
Depth below grade:
Materials of construction:—cast iron -(40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_L(locate on site plan)
a
Depth below grade:_
Material of construction: Xconcrete metal—fiberglass
— — _ __polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) /
Dimensions: `ay
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 34
Scum thickness:—__c9_ q
Distance from top of scum to top of outlet tee or baffle:_7
Distance from bottom of scum to bottom�orf outlet tee or baffle: I y
How were dimensions determined: l/!�cs a/`t�
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage etc.): Q �/
ffAa v a�.�c�l Yk �
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:—concrete_metal fiberglass olyethylene_other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet t r baffle:
Distance from bottom of scum to bottom outlet tee or baffle:_
Date of last pumping:
Comments(on pumping recomme ations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evide a of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTTEM/J INFORMATION(continued)
Property Address:
owner- -4:1 I'i'a
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumpe at time of inspection)(locate on site plan)
Depth below Bade:
Material of construction: concrete m fiberglass_polyethylene other(explain):
Dimensions:
Capacity: Zinworldng
Design Flow: day
Alarm present(yes or n
Alarm level: rder(yes or no):
Date of last pumping:
Comments(conditio of alarm and float switches,etc.):
DISTRIBUTION BOX: k' (if present must be opened)(locate on site plan)
Depth of liquid level-above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage iMo or out of box,etc.):
PUMP CHAMBER: (locate on site )
Pumps in working order(yes o o):
Alarms in working order s or no):
Comments(note cond on of pump chamber,condition of pumps and appmtenances,etc.):
8
Page 9 of 1 i
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSUkFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- SYSTEM INFORMATION(continued)
Property Address:
"5il'b!
Owner:
Date of Inspection: of j-�/n
SOIL ABSORPTION SYSTEM(SAS): A (locate on site plan,excavation not required)
If SAS not located explain why:
Type
teaching pits,number._
leaching chambers,number:
leaching galleries,number: t/
leaching trenches,number,length: 02 j r
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): t
4rle sb
b r r--
CESSPOOLS: (cesspool must be pumped art of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver
Depth of scum layer:
Dimensions of cesspool:
Materials of construction-
Indication of ground r inflow(yes or no):
Comments(note co ition 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 conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
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Page 10 of l l `
OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: AV
a
Owner:_
Date of Inspection: WAQ b�
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
. t
J
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Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLLNUTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS T EM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 06
r+f S
Owner: Ae' / 0
Date of Inspection: .�Z� Of
SITE EXAM
Slope Nv. 0
Surface water 13
Check cellar (0!
Shallow wells O
Estimated depth to groundwater 6 3'feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how y u established the high round w to�f e�levattion-
C 'r�UV�& y`0.LO
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P4erm.f Wurni�er: �=
b:
SIGH GvRC3UND—WA:YER LEVEL COO MATtON
Locabon- (Dd -9 L) �`�S �t cnnb� _ Lot NO-
r: :
Address:
Notes:
Meamire h to vww tale
4C nearest?i1£Bt - as b6 Osoo_..---------- Clete
of s z B i Map iaeyft
c�1eanddetem3m:
3Yfmiazte index te3'.._ ......
-r7 I
eTc--tevR T8#9je Zone ----------•-----------•---•----
i
&.tam ine CL.rrem depth TO 6 a 3
f-nr index -
? ; s
mdm
s
-------------------- ------
��Ztei?E�3t2F-'s21tE7 # sF9"zPFi�iIB
i
STEP 5 Estes depth w bt9h vwalez s
Subt—nq thec'g ` i
#a +m Wired zh to g J t
a