HomeMy WebLinkAbout0109 STETSON STREET - Health 109 Stetson Street, Hyannis
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No. I 1 C!/rlf Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: /
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplicatfon for Bigogar *pgtem CCotvaruction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. o� S�'ETSd� S"�, Owner's Name,Address,and Tel.No.
Y"/J1 S P�401-A �4 V/)L'TT
Assessor's Map/Parcel 14 P 4E14$ —��P` M
Installer's Name,Address,and Tel No. 509—q77-S'977 Designer's Name,Adiress and Tel.No.
Cef®&'lv106 tj/
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 Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of H alth.
Signed Date 7" 'ig-pZO��
Application Approved by Date �(g /2�9 1
Application Disapprove Date
for the following reasons
Permit No. � Date Issued `-f ('8 26(
1Vo. I I Fee
{ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH. DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplication for i,5 ogaY gterrY �Con�truction Permit
p
Application for a Permit to Construct( ) Repair O Upgrade Abandon pg ( ) ( ) ❑ Complete System ❑Individual Components I
Location Address or Lot No. 161 51( 501.11 S'r. Owner's Name,Address,and Tel.No.
oi*
H y u15 P�401-A -4 uD€T
Assessor's Map/Parcel O ( Ne I S W-r �?p U("_G M
Installer' 'Name Address,and Tel.No. 5o8— 77- 99?7 Designer's Name,Ad tress and Tel.No.
G'�fP6'dv(t�� �F� t.cG lj l� ,
T S-r
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) d Design flow provided'^
gpd
? Ian Date ' Number of sheets Revision Date
Title t
4 Size of Septic Tank Type of S.A.S.
Description of Soil
1
Nature of Repairs or Alterations(Answer when applicable)
8AZ00 6;Y45�(Xnw& le, SYS�
Date last inspected:
Agreement: r'
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 iu operation until a Certificate of
Compliance has been issued by this Board of ligaith. c
Signed Date �" (a"pZOL'4
Application Approved by �''�, Date
Ti
Application Disapprove Date
for the following reasons
Permit No. G�CJ� Y' �Tb Date Issued �
------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned(x)by !�,APO2(D&
at 169 STgTSo�j 5"T kk2- M 14Y?(Ac)1()(r~ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoZol'N-7.7 G dated
Installer Cs46u)(I)F Designer
#bedrooms Approved de�sig. flow A, gpd
l
The issuance th's e it hall n(it be construed as a guarantee that the system w f ®pc /as/Esi ned. r
Date Inspector / '
�-
�No . + t �- XF Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Di$pO,5aY *p5tem Congtructton hermit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon O
System located at ('�S���c � 51KIEI-�_t'Y l<:
and as described in the above Application for Disposal System Construction Permit,.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thispermit. -
Date r s/D,l/ (L Approved by/�-'��
LOCATION SEWAGE PERMIT NO.
to "'\Ttbo n �Ae +
VILLAGE
�AqGL 0
1 l R'S NAME ADDRE S '
(�C a
N U I L D E R OR OWNER
i
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��
1
1 �
09
-J
--17 �
Vu THE BOARD COMMONWEALTH
OF FHEAc TH Ts
/
O�
.............../-C W.n......OF....... .............................
A lira#inn for Diq nsttl Works Tnnstrnr#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (4_ ._an Individual Sewage Disposal
System at:
.............)D._.4.9..... /1 ....S7Y .. ..................................................................................................
Location• ess or Lot No.
........ .1� -•-•• --Ojbn.�.................. ••.....___._...dt,
!: ... ..........................................
Ownery /^ (..........-• Le!..�.................................•-----•--....
Installer Address
d Type of Building Size Lot.............................Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons____________________________ Showers
a YP g ............................ P ( ) — Cafeteria ( )
A4 Other fixtures ......................................................
W Design Flow........................................_...gallons per person per day. Total daily flow........................................_.__gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench—No. .................... Width...:................ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
�I
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
o
R; ................. -------^,--I - $$
ODescription of Soil............................... ------------ --•---•---••--••----•••-•-_...-.--•.........__.
x
c,
w
x •-..............................................................................................................- - ----------............------ --------
U Nature of Repairs or Alterations—Answer when applicable.......:.::::�_:_)jQD[�__._ _ _)2__ _ . __.____._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
'.ie provisions of'ITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
°ration until a Certificate of Compliance has bg n issued by h boa of liealth.
. _. ....__ Ll�
tion Approved B .:. ......... .........•--._...---••••......_..••--------•--.........•-•••---•-
PP Y /D
•- -••------- Date--•-------•---
s
i n Disapproved f o the lowing reasons:-•-•---•••-••------••---•--...--••-•--...••••---•---•--•••-••---------••-•....-•__________________•-•-----------
_...---•..............•--•-••••-•---....-•-•----•.._..........._...-•-•---.••-•-•-•---...--•-••-•-•---------••--••-...---•----•--•-•••----------__._-••---------•••-_-•-•-
Date
.................................................. Issued-....................................................... '
Date
r .
�. No.--3•--•----7----... Fss............ ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-- � �
o(III......0 F.......Bo., ............................
Appliration for Diipoiittl Workii Tomitrurtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( 4_ -_an Individual Sewage Disposal
System at:
.................. ......... ... .. .r:'_i.._...a...v. .. ........1...... ._.................. --•-•----•----•-••.......
_................
-• Location• �t?dlyessor
No.
.................... ................. -•---•---•-- 1. ...............................................
rry 't Owner to 1j Add�ies„ ,
W
--••-__.._�-- -'•��-- � ;t. ,, s... _�. .. .�`.� . ... "..r �" Lit .............................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms..................:.........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures _..--••••_._..------•-•---•••-----•-•--••••----•--._._._._...-.-••••••••....................••••-••-••••••------•--....__-------------............._..
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area____________________sq. ft.
Seepage Pit No_____________ _______ Diameter.................... Depth below inlet____________________ Total leaching area____...__._.._.___sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by........................................................................... Date........................................
,.� Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
RG -----------------
�.---______� } .o •---__._ -----r.............................................................................
Descriptionof Soil. , .�? _�........ = � `-•------•••-•••-------••-------•-••-•••••---•_______________________________
x
w
•-•----•---------------------------•----•---•-••-•-••---••••-------.______._._..._•-----__._---- •------•-----•._______ .......---....----------•-- ----•---......
U Nature of Repairs or Alterations—Answer when applicable....____.._____ . / _ ___.__ J. �........................
--------•_..••--•••-----•••---••-••---------------•-•...•-•-------_._ i�� Z----- -/-/
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI j 5 of the State Sanitary Code—The undersigned further ag ees not to place the system in
operation until a Certificate of Compliance has b n issued by It 4boaof health
' r j3
-•---......._A Application Approved B ` -----..-
Date
Application Disapproved f o the Ilowing reasons:--•••••-•---•••••-•••-----•----•----•--..:--•-••---•••••••-•-•••••-••-••-•----•-•_______________________________
...-•••---•--•---------------•---•--•-•••-•-•-----•••---••-•--•-••--•---•••----•-._...-•-------..........._......_....---•-----•----•------••----...•••----------•-••-••. •-•-.______•--____.._...._
Date
PermitNo......................................................... Issued_.......................................................
Date 1
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
• 4•n........OF... .r° 9'.Ji!. � ...............................
Tnr#if iratr of Tomphaurr
THISJS TO by
TA.hat tt�e-..I..n.
nd vi ua _Sewage Dispo 1 System constructed ( ) or Repaired (4,
..
at......... �.. � ;_� 5 .6)1-' e y r+i°a'/ Instab�14,0 _!�I_? .Ss�)/.� �P
•..... - ...................................... ..
has been installed in accordance with the provisions of TI ` of The State Sanitar Cod , as ribed in the
application for Disposal Works Construction Permit No. �_k7f________________ dated :._. .._.._..._.:_..__.___.._..._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL NCTION SATISFACTORY.
DATE..... °.y ........................................................ " Inspector,.... ...........................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........O �� �3471 7a4��7 F........M ....................
No.
FEE. 1.. `rt1
iuouul urk C�onur ton Fad
� .
Permission is hereby granted. i��r( � f°?' ==---••••-.__f..•- _c............................
to Construct ) or Repair -) an Individ al Sew e Dis o-4al System � 11
at No_____________ f.�-�'�-•.......r Z ....... -�y� 5
9'treet
as shown on the a plic tion for Disposal Works Construction Permit No......... ated..........................................
!� oard of Health
DATE------- ....... -- --.....-------------------•. y
FORM 1255 A. M. SULKIN, INC., BOSTON
�\ too-
COMMONWEALTH OF MASSACHL•SETTS
ExECL•TIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPART3IE 'NT OF ENVIRONMENTAL PROTECTION
1W
ONE WINTER STREET. BOSTON. NIA 02105
U-ILLIAM F.WELD 7RtDl CG>.
,,:
Govern- _ •o: ... Se::_
ARGEO PALL CELLL'CCI _.-...:._ DAN•ID B STR L�...
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Corar,issier
PART A
CERTIFICATION
Property Address; 1Q I ST IS_V� STi 11'� NHS __.y Address"of Owner:
Date of Inspection: 1111°�I/`�7 -(If different) V3'[_ ►n°�wS�A'�NRw�`�T
Name of Inspector: lYw rA Q o +' �I I ED ec 5•�;°�.M���1 t N11�
am a DEP roved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) O'Z,To��
Company Name:11-/ap a H4,•e Ce, r', 7•, 0-c P A
Mailing Address: Re-) !3 o;t e_37_P
Telephone Number: rSG -1
CERTIFICATION STATEME\T
I ce.^.if1 that I have personally inspected the sewage d!sposal systern at this address and that the information reported be-ow is true. accurate
s h in ect.on was performed base- on my training and experience in the proper func;icn anc
and comole.e a: o•the time or �n.pect o The sp pe g
maintenance of on-sae sewage disposa; systems. The system:
- Passes _
_ Concioonaii% Passes
tieecs Further Eva!uat:on the Local Approving Authont%
Inspector's Signature: Date: y
T;ie Ins.-�ecto• sha!' submu G a copy of this inspeoon reoor, to the Approving Authority, within them, (30) days of completing thisinspec,ior.. If the system is a share- system o• has a des,gn floes• of 10,000 gx or greater, the inspector and the system owner shall submit
the report tc the appropriate regional o ice of the Department of EnvirenmeriW Protection. The crigma! should be sent to the system owne
and copies :-nt to the buyer, if applicable, and the approving authority.
INSPECT10% SUMMARY:' Check A, B, C, or D:
Al SYSTEM PASSES:
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.30=
Any failure criteria not evaluated are indicated below. .
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, ueC
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no. or not determined (Y, N,-or NDi. 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; c
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan'
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
trev-.s*d 01/25!97) Page 1 of 10
- PART A . .._ -..
- CERTIFICATION (continued)�'.i:1°� '
Property A yes - -- • -
Owner:
Date of Inspection: _
BJ SYSTEM CONDITIONALLY PA55E5 tcontinut-d
_ .r
k r d
due o broken, obstructed
v ! observed in the distribution box is d t b o e o
k t o- high static ware. level obse ed
Sewage backup or brea ou g
pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
_ broken pipes) 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 twith approval of the Board of Health): --
broken pipers; are replace:
obstructior is removed
HEALTH:
- - - - -
Y HE BOA
RD OF HEA
REQUIRED B T
CJ FURTHER EVALUATION IS
Conditions exist which require further evaluation by the Board of Health in order to determine if the iystem is failing to protect the
public health. safe-and the environment. __ _ ,_,r•:: = . -
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or prn-, is within 50 feet of a surface water
Cesspool or pnr-, is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE-) DETERMINES THAT
THE SYSTEM 15 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 feat to a surface water supply or
tributan• 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 supaty 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 thar. 100 feet but 50 feet or more from a
private water supply well, uniess a we!] water analysis for coliform bacteria and volatile organic compounds indicates tfa
the we!I 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 04;25197) Page 2 of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.M
PART A
CERTIFICATION (continued)
Propert} Addross:
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate ether "Yes" or "No" as to each of.the following:
I have determined that the system violates one or more of the following failure criteria as defined in,310 CMR 13.303 T ne bars
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correc:
the failure. ,
Yes No -
Backup of sewage into facility or system component due to 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 S.AS or
cesspool.
Sta:tc licu;d level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspoo;.
Lieuid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov.
_ Recuired pumping more than 4 times in the last year NOT due to clogged or obstrueea pipes .
Number o'times pumped
Any portion o'the Soil Absorption Systern, cesspool or pricy is be!ow the high groundwa:e- e!evanon
Am. or;on of a cess ool or r►%-v is within. 100 feet of a surface water su iv r ri surface w i
R P P pp o t bu,�n to a su ace ater supp
1
Any portion of a cesspoo: or pri,.ti• is w ithir. a Zone I of a public well.
Arn perio- of a cesspool or privy is within 50 feet of a private water supply we[!
Arn- por,,or. o:a cesspool or prwy is less than 100 feet but greater than 50 fee; from a pri%,a!e water supply we!i with no
acceotabie water qualm analysis. If the we!1 has been analyzed to be acceptabie. an.ach cop'. of we!I water ana!vsis for
coliform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
Ej LARGE SYSTEM FAILS:
1 cu rust ind;caie e:,he• "Yes" or "No" as to each of the following:
The fodiow;rg criteria appw 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 systern is located in a nitrogen sensitive area (Interim Wellhead Protection Area • UPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 ChiR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
Pace 3 0' 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO'% FORM
.PART B
�.... 'CHECKLIST
Property AddEess: ,
Owner: 'AC fAA'rj
DtDate of Inspection:
1
• You must indite either 'Yes' or'No"as to each of the following:
Check if the following have bee n done. o
indicate.. _. . •
Yes tvo
vi by the owner, occupant, or Board of Health.
r ded
W o
ion as
rmat _•nf P
Pum
ping
in information�•. P g
I _
_ hone 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 recentl% or
as part of this inspection.
As bull' plans have been obtained and examined. Note if they are not available with N/A.
The facair� or dwelling was inspected for signs o-sewage back-up.
Tne s%-stem does not receive non-sanitary or industrial waste flow. -
x The site %%as inspectel for signs of breakout. .
AM sv ten- components. excluding.the Soil Absorption System, have been located on the site.
_ The Sep:.c ta-k manhoies Kere uncovered. opened. and the interior of the septic tank was inspected for condition of
baf ies or tees. materia` o construction. dimensions, deptn 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:
_ The fac-ia, o,.rie• tans occupants. if dihe,en: trom ow•neri were provided with information on the proper maintenance of
Sub-Surface Disposal Svstem.
Existmg information. Ex. Plan at B.O.H.
_ De:erm-ned in the meld of am of the failure criteria related to Par, C is at issue, approximation of distance is
unacce:Dtabie (15.30231til
7.
(revised 04/75/57) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATIO%
Propert,, Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design floN �3.p.d.lbedroom for S.A.S
Number of bedrooms
Number o°current residents Q
Garba e
g g%'der (yes or'no-a1.' .-.. ...... __.._ ....-....
Laundry co-.'-ected to system (yes or no).,�'
Seasonal use ryes or no.:� -- ll
V%'ater meter readings, if available (last two (21 year usage tgod,:
Sump Pump (yes or no) - ..
Lac:date o'cccupancy
COMINERC f4LINDU'STRIAL:
Type of establ)shmen-
Design fio%+-_ga!ionsida\
Crease trap present. tees or no_
Industrial %'taste Holding Tani; present. Ives or no_
:on-sanitati -Aaste discharged to the T:tie 5 system. ivies or no
\%ater meter reading;. if availabie
Las.Fate o: o
OTHER. De4cribe
Last date of occ:aanc.
GENERAL INFORMATION
PUMPING RECORDS and source of nformation.
System pumped as par, of inspection: Ives or no
If yes, volume pumped• gallons
Reason for pumping
TY�F SY57E.ti1 r I
Septic tank,rdistribution boxrsoil absorption system
Single cesspool
Overflow cesspool
Prn�•
Shared system (yes or no) (if yes, attach previous inspection records, if any) _. .. .
VA Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: IMS
Sewage odors detected when arriving at the site. (yes or not •- -
(rwisod 04125191)
Pa4. 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'Propertv'Address: 6`( �5�
Owner: *T mc4
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) /
Depth below grade.
Material of construction: _cast iron _40 PVC _other (explain) = -
Distance from private water Supply well or suction Ire -
Diameter
Comments: (condition of joints, venting, evidence of leakage. etc.)
SEPTIC TANK: Lf 5 —_-
(locate on site plan
Depth below grade-
material of construction: concre:e _me:a _Fioerglass _Polyethylene _othertexplain _
If tank is meal. Ifs: age _ Is age conf;rmec b\ Ce^:fica:e of Compuance
Dimensions -
Sludge depth _
t
Distance from top o: sludge to bosom of outle; tee o- ba-;e
Scum thickness �t
Distance from top of scum to top o`outle: tee or bade
Distance from bottom of scum to bo-on o;outle. tee e• ba=.e
How dimensions were determined o3y'mla
Comments.
trecommendation for pumping. tordition o' iniet and outlet tees or baffies, depth of liquid level in relation to outlet i vert, truc(ural
integrity, evidence of leakage. e;c.i
MeA kbt - U W
GREASE TRAP:-
(locate on site plan!
Depth below grade:
Material of construction: concrete _metal Fiberglass _Polyethylene _other(expiain)
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 baffie:
Date of last pumping:
Comments: "
(recommendation for pumping, condition of islet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25.11) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner. V tTWV Vj
Date of Inspection:
TIGHT OR HOLDING TANK:—&t 7ank must be pumped prior to. or at time, of inspections
(locate on site plan, -._._.. _..__..__ __._................. ... __
Depth below grade.
Material of construction. _concrete _metal _Fibergiass _Polyethylene —other(explain)
Dimensions:
Capactn: galions
Design hoN galions,'da.
Alarm level Alarm in working order_ Yes _ No
Date of previous pu-nping
Comments
(condition of inlet tee. condition o! a!arm and floai switches. etc.)
DISTRIBUT10% BOX:OQS
(locate on site plan
Death o'lfc.u!d le4 aoo,.-e outie: im c_ fle': WLOt1Ra.�TNV (
Comments
tnote if vel a distribution is eaua'. idence of solids carryover, evidence of Je4age into or out of box, etc.) 51
S3W !?
PUMP CHAMBER:
(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.)
' I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART t
'SYSTEM INFORMATION (continued)J .
r
Propertt Address: 6y Sr 561AJ
Owner:kLTWV'61
Date of pecuon;tj�n�il
SOIL ABSORPTION SYSTEM (SAS):
(locate on sitepian, if possible: exca, ton not required, but may be,approximated by non-intrusive methods:
If not determined to be present, explain:
Type: .
its. number to
leaching chambers. number:_
leaching galleries, number.
leaching trenches, number.length:__
leaching fie)ds, number, dimensions.
oveniow cesspool, number
Alternative system - ---_
Name of Technoiogv:
Comments.-
mcp condition of 50:1. s!gr`s of hydraulic tat Iur , leve` of pon incg, c diti n of vegetation, etc.)
CESSPOOLS:
(locate on site plar.
Numbe, and co^f1g::ra:,0r
Depth-top of liquid to inlet Inver,
Depth of solids laye--
Depth of scum layer.
Dimensions of cesspoo:
Materials of constructior
Indication of groundwate-
inflow tcesscoo) must be pumpeC as par, of inspection)
Comments:
level f din
(note condition of soil, signs of hydraulic failure, o , condition of vegetation, etc.)
on p g
PRIVY:
(locate on site plan)
Materials of construction: imensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04;2S/91) Page a of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM I%FORMATION (continued)
Propert} Address: 161 5T�q,,
Owner: Tvavi
Date of Inspection: �5Ic17
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
y Q
2
1 e
R
Ft¢.ar.sZ—
39 6
Z- 11;T Q2- 4S
A3- ,46 63 - so
pr\�- &96
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertv Address �G�l S���Sa�•
Owner: �Ne-7"N
Date of Inspeciion: '1, 1ei�9�
1
Depth to Groundwater i Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record ~ =
Observation o-Site (Abutting property. observation: hole, basernent sump etc.)
Determine it from local conditions
Cneck with loca! Board o- nea:t^
Chec� FE.titA K1aps
Check pumping record--
Check loca! excavato,s. installers
t_se L SC: Data
r•
Gesc*ibe j.1 voi,.oN% v.ora= no%% �o:: es-,abhshec the �:E' GrOJnONater Elevation. (Must be completed
trav:aed :1,'25'S- Page 10 of 10