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Home My WebLink About0048 FIDDLERS CIRCLE - Health 48 Fiddlers Circle Hyannis F/R` A = 288 163 • o p 0 n a 8 ii 6 J No. , A5 Fee. Entered incom HE COMMONWEALTH OF MASSACHUSETTS ter: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLation for Mispo8al 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) [XComplete System ❑Individual Components Location Address or Lot No. Li S Fi� e r'S C irc4 Owner's Name,Address,and Tel.No. �J'�.c�M Assessor's Map/Parcel 2—$$ 6 N 5?4�L)e_y I Installer's Name,Address,and Tel.No. /5 3 nrwc at ST Designer's Name,Address,and Tel.No. G4tJer,�;c�2 t9vk_P 1h q J/� 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) PAA-t2" 5--�hZ— to yL► e-C t" TO R�LcL+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 Health. ed 4 Date j L Application Approved by - Date Application Disapproved by Date for the following reasons Permit No. "� Date Issued Fee ✓— No. I r ` '`'" . HE'COMMONWEALTH OF MASSACHUSETTS, > Entered in comwter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rptication for -MispoSal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade�>k Abandon( ) ®,Complete System ❑Individual Components Location Address or Lot No. Li C;ctat. Owner's Name,Address,and Tel.No. �oJYYldFvt `Je4��`f Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 153 td,,,,vw"141 Sr Designer's Name,Address,and Tel.No. a-7 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 t 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) P " Co yyv10—Gfi' To Date last,inspected: s 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 Health. Signed J 0 Date Application Approved by J j Date v ! Application Disapproved by Date f for the following reasons Permit No. Date Issued Lr t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance n. THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( :) Repaired( ) Upgraded( ) Abandoned)g)by ,r.c(.�c C,y �/,9v,S ej L LL at y� F.Ltc�(, ,,t.S has been cons cted i acco d with the provisions of Title 5 and the for Disposal System Construction Permit No. �2G Installer C ,-de �1 tG/Q�.y� Designer — #bedrooms Approved des gw gpd C The issuance of 's erm' s all &be construed as a guarantee that the system*P�n�ld�ion771 /\_� I ' Date Inspector (I' l / �`v v ------------------------------------------------------------------------------------------------------------------- No. 10144 Fee a 5�� 3XHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( / U rade( ) bandon System located at E,-Jd I e vc , C/ � v i 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:Constru tion It be pleted within three years of the date of this permit. Date YJ' Approved by TOWN OF BARNSTABLE LOCATION / �%Cj/ 2 �S G12C& SEWAGE # g VILLAGE_ C IS ASSESSOR'S &LOTZI g' 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �"1' �j -- (size) NO. OF BEDROOMS BUILDER OR.OWNER JllePt M.0, —S o"128ev PERMTTDATE: 9 COMPLIANCE DATE: 1 t 03 " 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 � 11 A6 (40 I k � No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH � .. 11 N OF 64r APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ( Abandon ( ) - Complete System ❑Individual Components 40 r-Qb L 6-9.5 CQ P-c-LC- 4\ .�4' BBr-y Locatio Own 's Name Map/Parcel# dress ATLo[# / A}� Tele hone# /jt�ller's Name Dner'sANMam ia� Address rj_ �1�j d�e�-✓ss 6 3- 1 �V J Telephone# ele one# Type of Building: Lot Size 10 4 000 Sq.feet Dwelling—No.of Bedrooms roo g Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required))16 gpd Calculated design flow gpd Design flow provided gpd Plan: Date - �0 ' 6 Number of sheets �_ Revision Date 54- Title Description of Soil(s)6-je , � LOOM Pl- "Zj"L D4nN 14446 ,Z 6j8 CD,�2sS� � � Soil Evaluator Form No.IV 04 G v Name of Soil Evaluator njj A) boy 1-6- Date of Evaluation * DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE S and further agrees n to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed to ��. Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 rr y - .` ., ., ., . ..i''~8 l,1t f •.i � .- . ...r..«.♦ �.Mn 9. fry:.. W`a,.'1'r .... � e Y .'! � .., {n.n .. •Y:' 1 I.i No. THE'COMMVCNWEALTH OF MASSACHUSETTS FEE BOARD" OF HEALTH... A OF" "w-S g I-Ccr APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade X) Abandon ( ) - Complete System ❑Individual Components 48 FIM L&PS 'Ci sec c �tl®& .Sg9B�y Mi'l2 Location �� Own 's Name �� P- *�M ifo�-• �` Map/Parcel# �� r��d J i Lot# Telephone# C L � tryst Iler's Na"meName � �, •I �� / ner�� " •tl Address x Address Telephone# Tele hone# Type of Building: Lot Size 4 000 Sq.feet Dwelling—No of Bedrooms roa g, Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures �p Design Flow(min.required)') + gpdry Calculated design flow (Z gpd Design flow provided gpd Plan: Date `' j b 6� Number of sheets Revision Date �rr Title 6 0V— D'escriptiori of Soil(s)4- Z 2 tz Lo Z 0 b._ 21 - Zb GD Soil Evaluator Form No.h4UA I I G s Name ofSoil Eyalulator 644 A) bay LI✓ Date of Evaluation- 2 � J DESCRIPTI6N�OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees n t to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. j Signed JJ to Inspections t � ,1r FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 TH COMM N K ( —— ALTH OF MASSACHUSETTS——— No. FEE ,-.BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: / �` at t dale V S C , V r r/e has been installed in accordance with the provisions of 3 0 9MR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.2a6 3- 3 )?' dated 8 1 I'J 103 Approved Design Flow (gpd) Installer / ` 1Q Designer: Inspector .J ` Date // / / ID3 The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No+ ll THE—COMMONWEALTH OF MASSACHUSETTS FEE -,)A BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is he e _granted to Construct ( ) Re ai)(� ) Upgrade / ) Abandon ( ) an individual sewage disposal system atVol c' /� 1! as described v v J in the application for Disposal System Construction Permit No. dated Provided: Constmn sha s per • LAIJ,,,focallconditi be completed within three years of the date of thi ons ust be met. Date dl Board of Health f✓1 FORM 2 - DSCP DEP APPROVED FORM 5/96 (� \ FORM 1255 (REV 5/96) H&W HOBBS&WARREN"m PUBLISHERS- BOSTON ' i TOWN OF BARNSTABLE LOCATION'_ / Q �� l@ °2 J$ C12 SEWAGE # 02 3 C 00 VILLAGEti 'l ASSESSOR'S & LOT997' I U INSTALLERS NAME&PHONE NO. j SEPTIC TANK CAPACITY LEACHING FACILITY: (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: Lr 9 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 ®4 k 'n f - COMMONWEALTH OF MASSACHUSE® ��'®'tl�itlS? p' x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR DEPARTMENT OF ENVIRONMENTAL PROTECTION ��w SyeJ jq�14p I N01103dSNI (131M TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Y" "A Owner's Naiiie: t Owner's Address: � �,,��. " � � gel Date of,Inspection: ' j _ [RECEIVED EC 0 5 2001 Name of Inspector: please print) Irv-1- ( /`D�Y7l0)* N OF BARNSTABLE Company Name,. , HEALTH DEPT. Mailing Address: -0-,. Telephone Nutnber:5(? �* 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 training and experience in the proper function and maintenance of on site sewage disposal systems. I am a 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 ail Inspector's Signature: Date: The system inspector sltall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 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 a ' ****T►iis report only.describes conditions at_the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different. conditions of use. Title 5 Inspection Form 6/15/20.00 page I Page�-2'oftl;l� � OFFICIAL INSPECTION,FORM NOT FOR VOLUNTARY ASSESSMENTS T SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPE.CTIQN FORM 4 PART A em CERTIFICATION (continued) r �. eP p y r Brio_ :4- Owner: f.. 1- JA Date of Inspection: e� Inspection Summary: Check A,B;C,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 to.be replaced or repaired.The system,upon completion of the replacement or repair; as approved by the Board of Health,Will pass. y r Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. . The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or;exfiltration or tank failure is imminent:System will pass inspection if the .existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: v Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass in if(with approval of Board of Health): broken pipe(s)are replaced obstruction"is removed distribution box'is leveled or replaced ND explain: The system required pumping more than*4 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 ND explain: 2 Page 3 of 11. OFFICIAL INSPECTION FORM -,.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: Ol 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety ai)d 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 any)..determines that the system is functioning in a manner that protects the public health,safety and.environment: _ The system has a septic tank and soil absorption.system(SAS)and the SAS is within 10.0 feet of a. surface water supply or tributary to a surface water supply:' _ The system has.a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and.SAS and the SAS is.within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet.but 50 feet or more from a. private water.supply well**.Method,used to determine distance **This system passes if the well water analysis,performed at a DEP certified.laboratory, 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this.form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION�FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ��/; r ,�'�Pn Owner: Date of Inspection: D. System Failure Criteria applicable.to all systems: You must indicate"yes"or"no"to each'of the following for all inspections: Yes N9 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 _ l Static liquid level in theAstribution 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 '/z day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number J of times pumped 1J 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 I ofa.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 laboratory, 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,provided that no other failure criteria are triggered. A copy of the a_nalysis.must be attached to this form.) A-6(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 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`wilesign flow of 10,000gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 If you have answered"yes"to any questibn in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR .. 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: w ma Date of Inspection: Check if the following have been done You must indicate"yes"or'.'no as to each of the following: Yes No 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? 4. 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? — Were all system components,excluding the SAS, located on site V _ 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 lased on: Yes no it Existing information. For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Pail C is at issue approximation of distance is.unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 1 I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: o /j a Owner: 7 X / -A Date of Inspection: d FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): Number of bedrooms(actual):._ DESIGN flow based on 310 CIVIR 15.203 (for example: l 10 gpd x#of bedrooms): ? Number of current residents: : - Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no)�'°[if yes separate inspection required] Laundry system inspected( es or no): Seasonal use: (yes or no): Water meter readings, if avai-able(last 2 years usage(gpd)): Sump pump(yes or noLAW— , QQQQ,, Last date of occupancy: ZC AOLti COMMERCIALANDUSTRIAL� Type of establishment: Design flow(based on 310 CMR 15.203); gpd Basis of design flow(seats/persons/sgft;eic.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the jn pection(yes o(/no); r If yes, volume pumped:. .gallons--How.was quantity pumped determined? Reas on for pumping- TYPE OF SYSTEM' —Septic tank,distribution box,soil absorptionsystem _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 front system owner) —Tight tank _Attach a copy of the DEP approval ether(describe): wl.e. '✓ t� ,� �aCZ (� .. �L� 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): i 6 f Page 7 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI!'I PART C SYSTEM:INFORMATION(continued) Property Address: �- lq,4 Owner: �" Date of Inspection: IC 2 BUILDING,SEWER(locate on site plan) L(� 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 TANKNocate on site plan) Depth below grade: Material of construction:_concrete_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: Sludge depth: Distance from top of sludge to bottom.of outlet tee.or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): GREASE TRAIZ�: &locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8'of 1 1 OFFICIAL INSPECTION FORM—NOT FOIg':VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: d3 �('�t ��/�' a ,(/Z h by Owner: filnrz , <-1 ee/. Date of Inspection:_ I Z �9. -01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or'no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float,switches,etc,): DISTRIBUTION BOX &(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 into or out of box, etc.): PUMP CHAMBER:MMlocate on site plan) Pumps in working order(yes or no): ti Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 1. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION(continued) //// Property Address: Y�c iwh,9 P17� "XI Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ►/(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches, number, length: eaching 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; ' - 4 F/ 4 v7 f9 ,a . al-a-anz CESSPOOLS:�(cesspool'must be pumped as part of inspection)(locate on site plan) Number and configuration:. AW Depth—.top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: 42 Dimensions of cesspool: 00 � � Materials of construction: Indication of groundwater inflow(yes or ontments(note condition o soil, signs of hydr ulic failure level of ponding,condition of vegetation,etc.): J 46 o w�A, ' 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM . 'PART C SYSTEM-INFORMATION(continued) Property Address: Cf. .�-�*�_ � '` .0`0 Owner: � �Pe� Date of Inspection: 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. C-demue— S i 10 Page 1 I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) 0 Property Address: Owner: Date of Inspection: ' A2az SITE EXAM Slope Surface water Check cellar Shallow wells .- Estimated depth to ground water 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 you established the high ground water elevation: �. Ile 11 � >' s Permit Number:ber: Date: L Completed by: y } HIGH GROUND-WATER_LEVEL COMPUTATION r o . 1 dallee�'� fir' Site Location-:. C r!i Loy No. _9 ft Owner: A 1 Address: G1°T/ ✓'9,�9�5 I G Contractors lf/ ��/�'✓� Address �✓ G� r 5 �� Noes: 4' STEP 1 Measure depth to water table to nearest 1/10 =t. /j � i s ............................. .Date month%day/year I STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................................................... OB Water IeveLrange zone ........................:........... STEP 3 Using monthly report "Current. Water Resources Conditions" determine current depth to f / water level for index well ........................... `�`�� month/year STEP 4 Using Table of Water-level Adjustments for index well.(STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2.3) ' determine water4lC O v I adjustment STEEP S Estimate depth to high water by subtracting the water- level adjustment (STEP4) from measured depth to water level at site (STEP 1) .......:................................ ......................... igure 13.—Reproducible computation form. l ' f5 t . .... .... .. c� a i I I i I i I I u x - ®Cgs ®�� _ ��Eg��g _ � ® ■�IIIIIIIIIIIIIIIIIIIIIilllill d ..mom-IIlIIIIIIIIIIIIIIIIIIIIIIIII C■.�.�--��®� g ® mmmg®■�� -tee �e g� ®�� gL■ mm s��d■ ■�® � Ii iel mseg $g6Ggg _ oomC�e�C�m _. -- • g111Ili hll,ld9li�,, ' Cie NUM � onIIII ONION d� I®®I®®i �® ® ■ 111 'PI '1 P 1 'f ! g" g ■ I�� I,®J it i�!�li�' M 1!1'MIi9il,�'1�liEi4�aliliJ'I' i ®-e I®pia®I �■a ® _ - ��i�_� ■.tee _ g -g _■.� _ _ �■ m I® s - e f - -,__, , ---` - —---- - - - _ -,, - - - -- -, -- - ..-..__.. .-... r _mot ..,-_. , , , .. - i _ ;: - % . .- - - -. 1. ,- - - - - .. _ - _ .. . _ �. . - _ _ - _ - - .. - - ' '' . . . 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