Loading...
HomeMy WebLinkAbout0050 STETSON STREET - Health 50 Stetson :Street ,Hyannis P F q 306 076 ``s IJ �) (� 2 No. r" 3 � ) `L Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIPpYication for Misposaf *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon e ❑Complete System ❑Individual Components Location Address or Lot No. � �-� , O er's Name,Address, d Tel.No. 3 V .'7 7S- Assessor's Map/Parcel 3- 0(a p 174 1410_0 n t � Installer's N e,Address,and Te.No. �5—°J7/' 93 De igner's Name,Address,and Tel.No. i1' hs� cn:irk • OoY��g Q GSA 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) ' 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 E ' nmental de and not to place the system in operation until a Certificate of Compliance has been issued by this Board ealth. Signe Date Application Approved by t S Date 2 )} Application Disapproved by Date for the following reasons Permit No. 0 j—� Date Issued a f� I No. 2� r 3 0 — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Misposal 6pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑Complete System ❑Individual Components Location Address or Lot No.S��,k�h S+ Owner's Name,Address, Af ddress,and Tel.No. Assessor's Ma /Parcel t� lE�t^r 1 S a m �`( CClt9lec( 5v0 Sprt Sf-- p ,3UCp G"760 J ,' r1,44- 675e—eD Installer's Name,Address,and Tel.No. 624—91'>/- 93%y De4gner's Name,Address,and Tel.No. d-fix. 96V 411Q,5 ku-,s MA S. ,2/ Type of Building: t 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) r / 7 t ttr 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 Envirdinnenta Code and not to place the system in operation until a Certificate of J 'r Compliance has been issued by this Board of"Health. Signed/ n; / — -- -- Date7- Application Approved by Date Application Disapproved by Date for the following reasons Permit No. / 0 Date Issued s �, TH F COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS I TO CERTIFY, /that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(a�by Jjf-/0 at J` _5�2 � ►� P`Il( ni`j has been constructed in accordance with the prggvisio/ns/of,Tittle 55 Jand the for/Disposal System Construction Permit No.a b 13—�I�1 dated Installer ( jf�5 �fic„ _' 7no Designer #bedrooms ti Approved design flow gpd The issuance of this perm t shall not be construed as a guarantee that the sy/stem will tiorras esig,ed. Date Inspector_ --------------------------------------------------------------------------------------------------------------------------------------- No. 2 C)t — O Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair'( ) ! Upgrade( ) Abandon O System located at ��l) 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. p (� Date Approved by AsBuilt Page 1 of 1 TOWN OF BARNSTABLE E L LOCATION S U S�SdN 5T _ SEWAGE tt o2Ud-2-S/3 VILLAGE • f>!y/}NiU ASSESSOR'S MAP&LOT �")6—0 7b INSTALLER'S NAME&PHONE NO. t9iyNC'0 a 77S 2 F" SEPTIC TANK CAPACITY j('£ 01,4Cd LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER MC C—L� PERMITDATE: 16 43,;)02 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 OeAEi G c/ http://issgl2/intranet/propdata/prebuilt.aspx?mappar=306076&seq=1 2/22/2013 TOWN OF BARNSTABLEL LOCATION ->�� SS©�I/ T _ SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. t*�''Pi N C o `j n E' `7 7S 2 SEPTIC TANK CAPACITY C"T 0 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: f l' 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 - I I J 1 o � � I 3 r r N,o} Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: VIL/ PUBLIC HEALTH DIVISION -TOWN OF.BARNSTABLE., MASSACHUSETTS Ztppliration for Migooar 6pgtem Conotructiott permit Application for a Permit to Construct( )Repair( 'Upgrade( )Abandon( ) ❑Complete System E9' dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. - oS7 t Ts�,v s /U4 Al c'Y MIA),Cq uL r f' Assessor's Map/Parcel � Y r /� �-'V Installer's Name,Address,and Tel.No. :ra E"-�7 f'���/ Designer's Name,/Address and Tel.No. 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. 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 issue this Board of Health. Signed ate _a Application Approved by Date Application Disapproved f r e following reasons Permit No. Date Issued o. Fee �1r y ( Entered in compute' , / THE COMMONWEALTH OF MASSACHUSETTS Ye, t/ ` H DIVISION -TOWN OF BARNSTABLE PUBLIC HEALTH S MASSACHUSETTS 0100fication for'Mf 6 pooal *p.5tem Conotruction,Permit Application for a Permit to Construct(' )Repair( &o)^L7pgrade( )Abandon( ) ❑Complete System ®Individual Components 14*4 - Location Address or Lot No. Os-y. 3�� S�^- Owner's Name,Address and Tel.No. Assessor's Map/Pazcel. _, f�y: ���� ���.q`� �S'" - ?'d S F '4 f 7- 41f` Installer's Name,Address,and Tel.No. rJ'a 81 Designer's Name,Address and Tel.No. Type of Building: 1 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 s 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 tl a Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue this Board of Health. Signed / ate /D Application Approved by '� , t Date Application Disapproved f r t e following reasons f mot. 1 _ , Permit No. Date Issued ✓ ------------------------- -- ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that/t e On-site Sewage Disposal System Constructed( )Repaired( 41"Upgraded( ) Abandoned( )by CI�c O at 5,r/ w :i di as b ttonstructed in accordance ' with the p o isions of Title 5 and the fo isposal System Construction Permit No. •�"` da d Installer Designer The issance of�s permit shall not be construed as a guarantee that the sys e ill f�ut�ction�s esigne < Date 1 t b�- Inspector �l°J r� i �f ------------=------------------------ No. ! Fee v v I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=igozal 6potem Conotructfon Permit Permission is hereby granted to Construct( )Repair( -1 Upgrade( )Abandon( ) i System located at s(9 o 1� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to t comply with Title 5 and the following local provisions or special conditions. Provided:Construction st be co fleted within three years of the date of thi 'e .- Date: Approved by 1 TOWN OF BARNSTABLE e7c LOCATION SO 5 L &Ae - .1T SEWAGE # ?002—•_13 VILLAGE l�{��-Nfl1�'S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 146 �Xti C0 `S OF 'i`,� SEPTIC TANK CAPACITY 1 £ d'L/'r Cgr 7'"'v LEACHING FACILITY: (type) /��� (size) NO. OF BEDROOMS BUILDER OR OWNERA C C n,l e✓I PERMIT DATE: 1 vl 3 I U z 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 G�rAA �/e I I COMMOIv�WEALTH OF 1bZASSACHUSETTS / I EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDYCOXE Secretary ARGEO PAUL CELT UCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ��»» n /± Property Address: L-PI) Name of OwnergOU, 0t: =�16E Address of Owner• �jQ Z=_S ��y�,Er Date of Inspection: Nam :e of Inspector:(Please Print I T'��Lc_ I am a DEP approved system ans pector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CornpanY Name: F_,kAW2A4VA Mailing Address: Telephone Number: CERTIFICATION STATEMENT I certifythat I have personally p y inspected the sewage disposal system at this address and that the information reported below is true, ac urate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function an maintenance of on-site sew a disposal systems. The system: Passes p IC VEO _ Conditionally Passes L APR Needs Further Evaluation By the Local Approving Authority 2004 Fails .� 7000FBARNSf �y r� HEALTH DEPTi Inspector's Sigrrature: Date: 7 'Do \ �days `�. The System Inspector shall submit a co �'!� Y P py of this inspection report to the Approving Auth rity (Board of Health or' EPjw:ithin thiEta(30) of completing this inspection. If the system is a shared system or has a design flow of 10,000 e g gpd or greater,the inspector aqd 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. NOTES AND COMMENTS i D,47 A Or- revised 9/2/98 Pagel of11 %j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: , Date of Inspection: 3 A8 jCX:;) INSPECTION SUMMARY: Check A, B C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. 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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2ef11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �- ,CIERTIFICATION (continued) ca ner Address- ^ D ✓f r wrz:l Dat Inspection: �alp� e of Ins (i � 3 . 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9 2 98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: "Air, Cr Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 _ t/ Backup of sewage into facility or system component duerto an 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. V Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). / Number of times pumped_. V Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: N��t 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: 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9'/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: t� ft45; owner: � 1AJA Date of Inspection. Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: • Y� No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for-at least two weeks and-the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system.recently or as part of this inspection. AAs built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. r _ The site was inspected for signs of breakout. Y _ All system components, excluding the Soil Absorption System, have been located on the site. 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. / The size and location of the Soil Absorption System on the site has been determined based on: V �"•�.Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper.maintanance-of Subsurface Disposal Systems. L revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Sd S }�{,t"y4� Lw Owner: � e ,C - 1�+� Date of 1 pection: 3 !e'00 w FLOW CONDITIONS RESIDENTIAL: Design flow: CZaV g.p.d./bedroo Number of bedrooms (design): Number of bedrooms(actual): C� ,�� � Z 5D946 Total DESIGN flow 39Q Number of current residents^"1r-> Cl INDIVI M)Itt, t� Garbage grinder(yes or no):�f� p%57J Laundry (separate system) (yes or no). b If yes, separate.inspection required Laundry system inspected ( es or no) Seasonal use lyes or no):No Water meter readings, if av lable (last two year's usage(gpd): Sump Pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: 1�07 Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) b jU" 4 4 z?D If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM qQ ,81rptic tank/distribution box/soil absorption system mgle cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other Jwk APPROXIMATE AGE of all components, date installed Af known) and source of information: A41,_Zj32 s t / � Sewage odors detected when arriving at the site: (yes or no)TO revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: '67MW4 44Kils, O-Jhv Owner: et��� 3v�4 1c F,, Date of Inspection: It /00 BUILDING SEWER: (Locate on site plan) Depth below grade: "r Material of construction:_cast iron_40 PVC other(explain) Distance from private water supply well or suction line Diameter rr Comments: condition of joints, venting, evid ce of leakage, et .) GY�O0 �_ryc-/D d5� I 4 6;: c- J y*gsLe, SEPTIC TANK j �►�7C71 6 (locate on site plan '`r� Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) 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 dimensions were determined: Comments: (recommendation for pumping, coldition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural-integrity, evidence of leakage, etc.) GREASE TRAP:&I—'�' 7Pt�IU�L. (locate on site pla 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: (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.) revised 9/2/.98 Page 7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX- (locate on,site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:—&;r— � (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q� 4 V-C � IN" I � Owner: Date of Inspection- emu„ /1 — cc> SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetatio9, etc.) f✓ y aD !! GO CESSPOOLS: (locate on site plan) ��r► Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: (Z. Depth of scum layer: D (J Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of in pection) Comments: (notqAonditio_0 of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: Or (locate on site anT Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,*etc.) revised 9/2/98 Page 9oril � ` f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: 150 61t � Owner: C.7K�� W ,ice°� Date of Inspection: 31 {$� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t f / r ` i z3.5 z ( 37 # z 43 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �� �c7 LL^^VYSTEM INFORMATION(continued) 0 Property Address: � -Sr 1��4J 1S, Owner: E-S,'tV(TF- OF 0100-� Date of Inspection: -5/1 NRCS Report name (` 01— G L5b1c"'Ag Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked / Groundwater depth: Shallow Moderate Y Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Ob in from Design Plans on record V O rved Site (Abutting property, observation hole, basement sump etc.) r' D rmined from local conditions Checked with local Board of health Xed FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) kL . r revised 9/2/98 Page 11of11