HomeMy WebLinkAbout0071 REDWOOD LANE - Health T
REDWOOD LANE,HYANNIS
A= 288 200
e i
TOWN OF BAMSTABLE
LOCAi'ION�` ? K�� U-10 0 6 L-►r SEWWAG #
VILLAGE L4"7.4-et, rl kA 1 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. -�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 0 6f�i�;� ( e�
NO. OF BEDROOMS
BUILDER OR OWNER t 6 4e✓'t_:..
PERMIT DATE: "J 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-faciIIty) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist i
within 300 feet of leaching facility) Feet
Furnished by
x ,
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No. �_Lq 0 f P ( / Z Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pp[fcation for Oi5po5a[ bpOtem Conotruction Vermtt
Application for a Permit to Construct( . )Repair(r/�grade( )Abandon( ) Complete System ElIndividual Components
Location Address or Lot No.7 e" ctip()n Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ® ` c lie
I
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tell.No.
`k Lay`
Type of Building: g
Dwelling No.of Bedrooms J Lot Size ij 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 1,C7 C70 Type of S.A.S. f"CJ e7 L—✓�a/ J �^/ S�O� C
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Bo f Health.
Signed Date
Application Approved by Date 6
Application Disapproved for the following reasons
Permit No. Date Issued
i�:y.<�tin"4�'�,n�u`�"'� '�'�?' '' � r :�'� , , .sf ��,. x J `�n 3 s-s: ( ��',.�„a:;} �'�,.•,�,".,��e .ram—��. '� �°"`�a'��f'�,`�d—.C.�. ^m1�'id-,q.�_„ '�.� :� a •, '_ moist 'w�.� r .y � :.s�N L �.��
TOWN OF BARNSTABLE x �
; ' t,1po ✓� 1_►,�. .: SEWAGE # 00�^
LOCATION Ie
VILLAGE 1 4 4 r1 ki t ASSESSOR'S MAP_& LOT Z,?F-Z 00
INSTALLER'S NAME&PHONE NO: At
SEPTIC TANK CAPACITY
5.
LEACHING FACILITY: (type)
NO. OF BEDROOMS .
BUILDER OR OWNER
PERMTT DATE CdMPLIANC) . DA t E`
:Separation Distance Between the:
t
Maximum Adjusted Groundwater Table to the Bottom of Leaching Factlrty Feet
.. - ..I
Private,Water Supply.Well and Leaching Facility (If any wells exist
F
F f
Edge of Wetland and Leaching Facility
facility)
on.site or,within 200,feet of leachingFeet :,:
g (B•any wetlands exist
Feet
WIthin 300 feet of teaching facility)
P.
Furnished b i
7. S-
af
{ b�
L
0
No. ��0I _ V 7 Z x Fee _5 i
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01ppfication for Migonl *p5tem Convtructton Permit
Application for a Permit to Construct( , )Repair Grade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.7 wpDo Owner's Name,Address and Tel.No.
Assessor's Map/Parcel d O 0t / f
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: ._. ....
Dwelling No.of Bedrooms 2 Lot Size i sq.ft. Garbage Grinder( )
Other Type of Building /C 125 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 I Cj 610 Type of S.A.S. O
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Cprtifi-
cate of Compliance has been issued by Bo 0;" Health. '
Signed Date
Application Approved by Date 6
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 System Constructed( ) Repaired ( aded( )
Abandoned( by 1«k �_j e- Ld
at `I I R - "t-A-a 0 h has been constructed in accord nce
with the provisions of Title 5 and the for Disposal System Construction Permit No,. Zdy/ dated 7— 2 s-o f
Installer . /\,<—t.k-e L e_Q Designer
The issuance of this pMoto
hal not be construed as a guarantee that the syste 'll fun�ion a esigne.
Date Inspector
No. -----
---Z ------------Fee � '_.
,THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Aizpogal 6potem Construction Permit
Permission is hereby granted to jons }ct( )Repair S )Upgra e( )Abandon( )
System located at ✓i a a� w40 l� `i'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:Construction muy be co pleted within three years of the date of this t. r
Date: �� Approved by
4
%
No. f M5 O V
r r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[pplication for Migaal *pztem Con!Aruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
71 Redwood Lane, Hyannispor� Engelsen
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms C:P— Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) _Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 B and Health.
Signed Date `—
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
Engelsen BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X ) Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at 71 Redwood Lane, Hyannisport has been construe ed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No`.UV('
Installer Wm- E Rnhi ngpn Sr•, Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS
Application for ]igpogaf *pgtem Cowaruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
71 Redwood Lane, Hyannisp rt Engelsen
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms C:P— Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
t ) /1
Nature of Repairs or Alterations(Answer when appfi6 le) /7_;�Aa// 4 /✓` �"�
GC r7 d, �,AnGrC /+-t �tt�it��d0� i/'��.-sue PG�G C 1*& L'/'
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 B and qfirHealth.
Signed Date
' Application Approved by Date
,
Application Disapproved for the 1ollowing reason
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Engelsen BARNSTABLE, MASSACHUSETTS
4 Certificate of Compliance
r
_ THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
Redwood Lane H annis ort
at 71 r Y p has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No?4IJ(— 10
Installer Wm. E. Robinson Sr_ Designer f
The issuance of this pemit shallleot be construed as a guarantee that the sylst,,ll�functtonas�designed.
Date ✓ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS
Engelsen 'Wiooga[ *raem Congtruction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon(. )
Systemlocatedat 71 Redwood Lane, Hyannisoort
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: Construction must bb completed within three years of the date of this ,e it..
Date: / , Approved by /
�NOTICF-i Thk Form k To Be Used For theRRq it Of Failed
Septic SyMMS Outy.
C�f'II�IC.+►TION O)�SKE'>Et�AKD aPP>�IC�I'1gOI�i FOR A DLS�OSAL
WORKS CONSTRUC rION (WrCH4UT DESIGNED FLANS)
L William E. Hobinson,5zhenby cerpfy dhat the application f.►r disposal wotics
Vmw sigpwi br me dam
Prep"Jocatedat 71 Redwood Lane, Hyannisport Mess all of the
fonown g criteria.:
• The symm is o ccooed to a r�ud dwelling only Mwe arc,no comu=ciat or business
� onwsh the dwdfiu .
Thu soi is ciasvSed as C1.ASS 1 and the pemWuam cdw is l=wan.w cgaW io:5 minutes per i=b
Therc -no uvxbmh wig 100 feet of the ptepa wd scpuc k-tsew —
- Theei an privates wdb within bo ica di the prgtMd shout sgStaa
Them na inneasre m liawv anNaar in taut p MPMd
• are no variawm vagweswd ar ae uk&
bottom of the b=1=9 bmgtv milt mK-6e:to mad less than five few aba.the
dmm MW elevation[Adu g die gttmudtvtter table uwng the Fnmptor
when appkwcl .
11 the s 3.S.will be located with 250 Foes of any vgctated the bottom of the proposed
teaching facdkY will M be tamed km than founem 1141 fact.,d)gw dvc mamm m adjusted
gronadwau r tabk devadon,
',P lea=c=mpkM the ftHwwkW. ^
-A) Top of cm and Swbm Ekxmim cvift cas ,
81 G.W.EMatiott _+1k MAX ifgit G-w_ t
DIFFERENCE BETWEEN A aw€s
SIGNED: ..-�DACE:
(SWIM PMP05W Pbn O sysmm on bad[(.
-F tcW&
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Department of Public Health and Department of Labor & Industries
�1 NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply
with the notification requirements of M.G.L. c. 111 § 197
FILE NUMBER:
{ ✓�/ c� � '
y r7
Contractor performing project License# 4W10, 1996 W
Lead Paint Ins
Exp. Date
4l S lt�i I I r vh S
Inspector �C�uG—r License#
�-t Vi C a n f R-2_ �"-� �✓1 vi✓D h 1 h-c t1 d d .
� Date of Inspectio n
If low-risk deleading work is being performed, complete the following line: — '
Property Owner G ty itl L• 016 tr Y Agent(s)
Address of Project
Building Name(if any) Floor Aa
Street Address Apt. NX
City 1j4., y' Zip p�6 ,�
Deleading Method: Wet/Dry Scraping Heat Gun Liquid Encapsulant Covering
Demolition Caustics Replacement Other
If"Other"selected, please explain K&OV a ( o (2
Check One: dwelling is multi-family single-family
Start Date /l�/714) 6 Completion DateLP
When will work be done. pm - weekends? r IV-
Project Supervisor's Name b'�' License#
Property Owner�lC a hi Iy _ rYl be;-`/
Address P 005
City 4 n i Sr J✓�" State Wj6 Zip— Q1I
r
Telephone 6
In case of emergency contact z !xXA Old H f
Phone: day y _ �f_ �� evening
(OVER)
1
In accordance with Massachusetts General Laws c. 111 § 197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and
method(s)of removal or covering of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided
and must be received by the following
persons, at leastten (10) day-,prior to the beginning of deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if'any
3. Director, Childhood Lead Poisoning Prevention Program Fax(617) 753-8436
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02210
4. Director, Asbestos and Lead Program Fax (617) 727-7568
Department of Labor and Industries
Room 1106, 100 Cambridge Street,
Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency -io1j�a�� � 7 � 61�.a•-ti...�
6. Massachusetts Historical Commission, t- (If premises is listed on the State Register of Historic Places, this notification
220 Morrissey Blvd must be made upon receipt of an Order To Correct Violations or at least 30
Boston, MA 02125 days prior initiating preventive deleading.)
Fax(617) 727-5128
Deleading Contractor
The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth
of Massachusetts Deleading Regulations, 454 CMR 22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR
460.000, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief.
Date Signed:
Title:
Company
Property Owner(If owner or unlicensed owner's agent will be preforming low-risk deleding work)
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention
and Control Regulations, 105 CMR 460.175, for owner/agent low-risk abatement and containment. I further certify that I or
my agent will be performing the following low-risk activities (I have circled all that apply):
applying liquid encapsulant capping baseboards
applying exterior vinyl siding covering surfaces
emoving doo , cabinet doors, shutters
I certify that all the information contained in this notification is true and correct to the best of my knowledge and belief.
Date: -.3 A Signed:
C:\WP50\LEAD1995\FORMS\DELNOT.FRM Rev.10/95
x �
Comrnonwecatth fof MoMchuseits
Executive Office of Eh r onmental.Affairs -
epartment ®f
Environmental Protection 1,996.
, ,
William F. Wald a �>
aa«t+w rudr Cox* 4.
Argao Paul CallucciU.Gommm Do
CA
SUBSURFACE SMAGE DISMSA1,SYSTEM INSPECTION FORM
PART A
CER.TI VICATION
Property Address: -T uSv OO L �.1 (�-Y+"r,M (PZ'YLT— .
Date of Inspection: tj_3 Address of Owner.
Name of Inspector. �.%.0, r (If different)
Company Name,Address and Telephone Number. American ri0me f1 $flviromental jnc. -
35 Winter Street
CERTIFICATION STATEMENT Byann]s
1 oertih•that 1 have Massachusetts 02601 .�
Personally irupected the sewage disposal system at this address and that the information reported below is true,accurate
and Complete as of the tirne of inspection. The inspection was performed based on. MY training and experienoe in the.proper fuaet s, sad
maintenance of on-site sewage disposal systems .The system:
�easee
Conditiona y Passes
Needs further Evaluatio
Fails
n$y the Local Approving Authority
y y
Inapeotor'a Signatntts,�'�"�' �
Date. � 3,:
a1 W 0,k !'��1 11 atlbmlt fl
copy of this snspectwn report to the Appravrng Authority� .
lheayst,ft a shared sgrtem or her a � '($0)�11►+of Y
report to the appp�� ` �Pm men flow of.I0,b00 gpd or:groater,the inspector and:tha s�rstem
regJional:offiCe of the f Environmental P oanmer ahe�ll subrak the
The or�afll should be sent to the agstem owner and oopres sent to":the bu r
the ap
3'e rt applicable aid prov�ag'autliorrty
IN8P1�C'1'ION SUMMARY
CheckyA.B,C,or D
I have not found-auY rntormation which iadicatss that the Any system isolates"Y of the failure Criteria es defiaed.rn$10 CMR 15 303:
failure criteria not'evaluated are indicated below.
$l SYSTEM CONDITIONALLY:PA88E3: f
system Components need to be replaced or repaired The system upon aompletion of the nplaoerment f
Indreate Vas-no or`sot deferiniaed.� N;.or-ND): Desciibe basis of determination in all instances. If^not determined^The septic tank is metal,cracked,ecru
Y unsound, shows substantial infiltration or exiiltration,.or.tank feilui e is
imminent. The"ter will pass inspection if the existing septic tank is replaced with a Conforming septic fault es;upp
by the Board of Health.
(revised 11/03/95)
Da
- 1
4 ` ��111Ilt$irtAt t y a 80at0IA n 108 � n
k. �Y �✓1'l., � �,..± F.� � 1 � -.t.ly y � f���' .1�'� +. ��� � S S� 5 d
� ��: _y .l.:c• � Y'y��.L.SC. � .f L x :a°�`Y4 ^�" 'Y'.YT nr �Tt�yt� Y^,�y{��`�f7z{1���'���� ,N '�`r�W.k 16..,
}f
y F J f y 31 ? T
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SUBSURFACE`'BIsWWAdE"11I8P08AI:8Y8Tl�M>I4BPECTION Foam
PART A
CERTIFICATION (continued)
Property AddrRns:h 1 Cx�G � L_r. a,vt t3ponLI
Owner. C4-/ v i "k6o--
Date of Inspection: 7_-3
B) SYSTEM CONDITIONALLY PASSES (continued)
— Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due,to a broken, settled or uneven distribution box. The system will pans inspection if(with approval of the Board of
limlth): —
broken pipe(a) are rnplxced
obatruction is mmovvd
distribution boa u levell.wl or r�plsc,-d
— The system required PumPing more than four tunes a year due to broken or obstructed pipe(a). The system will-pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
. ob0-r action is.removed -
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require flu'ther evaluation by the Board of Health in order to determine if system stem is failing to protect
the
public health,safety and the environment.
}
i). SYSTEM WILL PASS UNLEBS.BOARD of HEALTH DETERMINI�9 THAT THE SY81'EM I8 NOT FUNCTIONING IN A
MANN>i:R WHiCH`WILL PROTECT THE'PUBLIC HEALTH AND SAFETY AND E
W"RONMEN'1`
_ Gapool.or privy e within b0 feat bf a surface~ water. ,
Cesspool or envy is within 50 ket of a bordering meted�etlaad or a salt'uia:sh
9). 85t8TEM
WILL FAIL Ur1IES3 THL BOARD OF HEALTH LAND.PUBLIC WATBt Sty
DETF ., PPUSK IF APPIROPRJATE)
TEAT THE BXSTF.M Tg FUNCTIONING IN A MANNER THAT pRpTRGT TgE.PUBLiC HHAITH AND
SAFETY AND THE ENVIRONMENT•
The system;has a+optic tams swd soil absorption
sarfaoe water*UP*;'' of ?9 to
r:
system and;is within loo feet co a surface
���PPkY a
flu-
system systram`hae a septic tank and soil abwrptaon system and is within a Zone':I of a public water atippT9 soe11
Thesystam':has a ieptsc task cad soil absorFtioa system and,is within 66 feet'of a private pater supply well
.:The.syetem.has a!BPS tack and sal
and>r less than 100 teat but b0 feet:or nare;from a psivate
du -we `'u�ss a:weU w tw.atiebsu.foi'oolifw=bacteria and volatile grater
from pollution 5om that tacihty and the ° C�oartt.Ptatnda iadicatM tivt t>se well b'lkse
> presence of ammonia nitro8tzn and aitrata nitrogen:s equal to or bW than 6;ppm
r .
r
.(revised 11/03/95) 2
1ti
� t
j�s � } �,�. ro:k r.".��+�6'rF�i._t' r. a •s' a o-^e, 't s _+w+.�c+�:r� n ��t~,n�� -�'f i�.' f� t '' t�� ,�` �§ �c.T :�b*k t .c �-x-. .pa : a"
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
. i
Property Address: 7 j zsup L rJ cZa 1'1 t1 a+&
Owner.
Date of inspection: .�
Check if the fullowiiig has ,, kwen done:
- I
tL_
� i
Pumping information was requested of the owner, occupant, and Board of Health. 1;
' IJone of the system components have been pumped for at least two weeks and the system has been reoeiving normal flow rates
daring_that Period'. LWV volumes of water have not been introduced into the m recently o '
4/ Ax
try r as part of this rn�pectioa.built pleas have been obtained and examined. Note if they are not available with N/A.
�TLe facility or dwelling was inspected for signs of sewage back-up.
lThe.system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
YAil
'✓All system a mPonents,a cludtng.the Soil Absorption System, have been located on the site
V The septa teak manholes-were un
tees maternal of °P° and the interior of the septic tank was inspetedrL oondtpoa of bra or
canst:uetion,&menmona, of liquid,depth
dePtl° of sludge,depth of scan j
�TI;s saw ami location of the Soil Absorpgon�� . System on the site has Dees detetminsd based ott' 5 � - t
f ,ty o vner'(aad pecu }Iran >f diiereat from owner)were prove
$urfaoe Disposal. P� atenaaoe of Bub
System
to
ded with mforaiatioa oa"the
A 'Ira
(revised 11/03/95) } '
4
i'r �>; �,` yt•-+"�� ra t..a. .� `� �a�-� }t -. `52 : a.3�,, ,.,. ,..4 -.8�rs � �.f.; K ,t �z �. t. K ns r
, 7Fz;..�y+'aKc � �S F.� �'�..,�'•-� ,t -. t2a�w3�.�o�s � -�t,"E�W �s �.,u h��, ;.a�r�' �' � i
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BUASURFACE BEWAGE`.1618POBAL SYBTEM`INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: '1 ( Z`e44_c,,;coc1 I�r� �'/}sQIJ et p. oz T—
Owner. C64_C7:�j (Y01E'&Z(,
Date of Inspection: "7 - _ct
FLOW CONDITIONS
RESIDENTIAL:
Design now:_LjLad_j�sljonq
Number of bedrooms:_
Number of current residents: 2.
Garbage grinder(yes or no):-tic)
I,aun conn-LDd to f
dr3 rysU!m (yea or no):�
Seasonal use(yea or no):-9-0 �!A
Water meter readings, if available:_-
Tat date of occupancy:
COMMERCIALANDUBTRIAL
Type of establishment:
Design flow: gallona/day
Grease trap present:(yea or no)
Industrial Waste Holding T nt:'(yes or no)_
Non-sanitary waste, to the Title 5 system: (yes or no)_
Water meter readings' available:
s
Last'date of papry
Let to of occupancy.v 4
r •
GENERAL INFORMATION {
PUMPING RECORDS;and source of information:
artwaT, l.e .�= 'a,n►€s2 //-;30-y d
System Pumped as pert of Upecitoa -(yes or no)
if. .vohrme' ttmped - sailoaa.
Raaron for ParPin6 Sv�9 ) Puvr�P�n1g 9�/S7Y3'-s+'t
:
TYPE OF HY8TEM t
— SePtu soil absor mn system
Bfag{e;oesspool
Overflow Cesspool
Privy
Shared system(yes or no) (if yes,attach-previous inspection reoords, if any)
Othej
APPItOXUiATE AGE of all oomponente,date installed(if]mown)and source of information: _ ��►LDf"y y7 / �} :"j•a
Sewage odors detected when arriving at the site: (yes or no) NO
(revised 11/03/95) 6
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_AC 3 S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Addrenssn: I % �t((�� L v� �f}n/IJ(Soc91I�—
Owner. t��4aaC i' j 1
Date of Inspection:
SEPTIC TANK_✓
domte on rite plan)
tt
Depth below grade:_ I fi
Material of construction: ncre •`wetal,FRP _ot.her;explain)
Dimensions: / X X 8 --
Sludge depth:a`,
Distance-from to of sludge `t p dge to bottom of outlet tee or battle:SO
Scum thickness:—_
Distance from top of scum to top of outlet tee or baffle: T I f
Distance from bottom of Scum to bottom of outlet tee or balTle:
`-'Comments:
(recommendation for pumping, condition of inlet and outlet teen or banes,depth-of liquid level in relation to.outlet invert,structural integrity,
evidence of leakage)etc•) __t�P jno-* �UV%.a r%r'o D
a>t sE T>�l�
abate on site plan) ¢
ii
eonst�uction concrete_.metal_FRP._other(ezplaui) ,
a Mine dons r
I?istpnoe top of.fcum to:top of outlet tee.or baffle
Distance bottoat:of noun to bottom of outlet tee ar;be$1e:
OeOOm foe•pumPmB condttwn of ialef end outlet tees`or baffles,de' '
ev}deooe of pth of hquid level is relatst»a';to outlet fnvett,strttt may,
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a 8U$BURFACE BEWAtIE Dt9i'mBAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oonttnued)
Property Address: ( g j cJ 6 0� l-N 4 2-1 A ,S.P d7(r
Owner. Cxre -, h�C�2'vTz t_
Date of Inspection:
"? -3--ct
TIGHT OR HOLDING TANK_
(lomte On site plan)
Depth below grade:,_
Meteruil of conatsvction: _concn-te`metal W _other(explwin)
Dimensions:
Capacity:- call
Design flow: ons/day
Alarm level:
Comments:
(condition of' e,tee, condition of alarm and float switches,etc.)
- r
D
ISTRISUTION SOX`
(locate on site plan)
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i
PpPth Of IsQtttd'level above Outlet invert:
(noted level end distribution is'equal,`evsdence of soltds,,cerigover,.evsdence of leakage-into or out of boat,etc)
PUMP;CRAM JbL
.(locate on wife plha) -
Pum"in working order:(yea or no)
Comment:
(state"condition of PUMP tion of pusaps And.appurtenances,etc.)
77777767 .
(revised 11/t)3 95
5
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71d
a '� ?�� '.'� nr•fit.}'°ka' -i C .rd ta'r• '.,*T� sy t a +• � �s � § yl
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SUBSURFi► AQR DISPOSAL SYSTEM INSPECTION FORM ..
PART C
SYSTEM INFORMATION (oonlinued)
Property Address: i /v-C_ L r.. c�1 h ��,�d fz- _.
Owner. C Afa� I�fiO(t
Date of Inspection: 7 _ 3_Ci
SOIL ABSORPTION SYSTEM (SAS): Y _
(locate on site plan, if possible,excavation not required, but may be npproximat.d by non-intrusive methods)
If not determined to be present, explain:
(�v C ol—i EZ>
I"Ching pits, number:..:
leaching cbembere, number: _
leeching galleries, number:
leaching trenches;numberilength:
leeChinB gelds;number,ditneasioac:
overflow cesspool, number:
Comments:(note condition o it signs of Wesulic failure, level of Pon ding. getation,etc j
Po fig.condition of ve
Z AG L t...
CIi6SP00
h it and
• 4
Deplh'taP of hgoid to inlet'
•Y �� R t M
-:_Depth,.M atxun]gper•. �:- .. .�: ': - - 1e ��' ;
Indication water:,
( m11tit be Iuin P""` 'lneplCttOII)
a �
L'OmtneIIts (Hate OOmdlt2pn Of soil,signs Of.bydrewyc failure,level`of pond:ng condition of vegetatio2l,
;i
PRIVY:
(locate on site plan) _
materuk of
(nole:eo n of. sig u:of kgdreulic Wore,IEvel of conditioII
Pondine vegetation,etc
(revised 11/03/95). 8 .
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'8l>219U.RFACE;9FW.A 3F,I)18P09AL,SYSTEM INSPEMON FORM
PART C
i 81,STEM INFORMATION (aYntinurcl)
Propool Addr&uv r i Coon
Opwncr. Cq-,� ME�1-e_(
Date of Inspection:
SKETCH OF 8MACilk DISPOSAL'SYSTEM:
include tiau to W locum two Fwr-nuiur'nt. naerencer, lnnrinu'trke. rr 1,nrlun,rir
locate e11 welly within 10i;'
took r.
w y�
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fi m� AM
qn, Not ontoPAYS
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t. E t ? N
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AN
tic ?AW
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TOW"0i 7cot
1 L. x
J.
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TZ
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D> 1PTFi'i<,O CaOUNDI Ali K
x l�pth to SM tulwater.' •.r3/, feet
method of d+etermiantioa or aWndmation `gym fhl(_
Y
(revised 11/03/95) 9
E
{ � Y
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5 4-
st rt .x a��'��',�' k� -.,y�x z - ti� � � � aA - �'''-X�{'�u +✓ �'7�,7S2r�M1 �{ �h 7- �f� �Y�,..,`v+�s 44k '�'�'j°`h..°3
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