HomeMy WebLinkAbout0081 ABBEY GATE - Health - 81 Abbey Gate
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TITLE,L 5
OFFICIAL INSPECTION FOR-NJ NOT FOR VOLUNTARY ASSESS'IM TS
SUBSURFACE SEN AGE DISPOSAL SySTE-M FOIT;Z:�I
7 PART
CEIRT�IFIC ATIO: ,
Pr operty Address:
o 141 A A
Owner's Name: a✓ o,^�� ��
Oevner's Address: g/ de low i►l ^� b b "' a ;
o ��
C � � a G
Date of_nspection: C,
IF
Name of Inspector: (please print) / "/Cy y-1r- At,/sue
Company\'ame:
)-failing Address: —/.fO�C
Telephone dumber: ,S-08
Cn r_
CERTIICATIO`N' STAT"IN T cn
i Celiliry t;^.ai I Nave personally inspected the sewage mg ;G'Sa_'$Tic` yj a.�:. _
''below is true, accurate and Cor riete as orthe �e 0' u and cj�e='o�uInor. -cr:�'�C
the s ecuea ine sLec en;u.as ne'omee used on-I;v
1aiPin2 and exile fence in the nrepez`unction and maintenance o`on site se vag-e disposa?s:- to c
approved system inspector pursuant to Sect on 15349 of Title 5 31f' -" ns. I am a OEP
( CMER 15.000). z a e S--:-e-:,.
k- Passes
-- — Cendienail passes
'ds:u cT1 ialis 0? ` re Local Approvi--crr
Inspector's Signature: GDate:
rSLzi-
,_:
DE', �r:li-�v days of cc~ ,'e no LL �.z moo;- ,�cazd o _ea_�_
1 t s_:specdon I ne s .a a shared yste -,
c_l . It=e : s✓eco grid .._, s:pie or-.-:r: ., -. _-1 r `e- .n,, �e - - --- -
aDJ
ard Cc _u eats /s-
H/C7
' s Annrt
ieciion. Jf..�..0 1.o: .. E
C t l`ci 3 S f,f L'$e. ' 'L 1 u norm in ;' re -
�ti1_ -1�_r .hie Sa: 'Fr-
Page 2 of 1 1
OFFICIAL INSPECTION FORA—-NOT FOR V'OLLT_T_�RY ASSESS UE\TS
SL'B:ST"RF_4LCE S1ET+ ' GE IDZSP®SAL SYSTEM I-NSPECTION FORM
PART
CERTIFICATION(continued)
Proper—ti•address: �/ /��� /'_ _/_ �� •
o ----��—
owrer• G.�So✓I 4
Bate of Inspection: 0
Inspection Summary: Check A.B.C.D or E i�IR_a�'C complete all of Section D
A��T
7ha-,,-e
Passes:
not four.d anv i
_P.iOii�_atiOn, w'i7IChIld.C^-��that v 7
1�..303 Cr Ln�i v CN_ -=•iQ=6 e r •c c"' --of the:aili,tre Cri-e'a des..r'!,;1ed f.:in Ct` `R
:i 5 . ._ .a2ture C-teiaa_r.OI eval aped are --
�L!Il.4L'
Comments:
B. System Conditionaliv Passes:
"
_ �`0` eC C
repaired. ---`' S 1 e _' - n, -�'' 0 reu_a`
Sre r_. a _3 CC 7 H1eii0r Or i re'Dlacemt!az Or repair,2S evp-0 'ed j�: = C.^_ ^Health.7_
-- '�a ll or Health. -ass.
'-sv e: ves.no Or n t QeieZ�T1 Ilea '\7 r
p ) `tihe for the following StateLents
explain. . If"nor det,---nmned" �.earz
THe septic tank is metal and over 20 years old*or the septic' -<;whE; e-az ;uI c`rall'.
unsound. exhibits S ibsrzrtiai in-ihraiion or exf;:rat10=Cr t3 {cLL Lre i g t
existing tank is replaced with a cernplvinC a =; 'Pec= "e
r septic���as approved b-�+� D �
��e Board o;Heal- .
a r fetal Septic tank-will pass ZSp tOTI if It is Struc-LurallV sca d,not leaking and if a Certificate Of COl_viia Ce
ii dicatinJ that the tank's less han 20 years old is available.
ND explain
Observa on of se-wage o ,.. .
backup r break olt or hi h static water, level ine dis ,buti0n be: o
ebst_racted pipe(S or due to a broken_seLued or uneven d:s�ibt i
approval f Heal. , or box. SY 'M��:,ii pasS .s p 10�3oard o� gib,:
broken pipets?are r-placed
obstruction is removed
d str-/•butien box is ieL'efed Or replaced
ex:)iain:
`':he scs te_ , r
__.=cu
ro
ec�1111L �g
ass 1nsa c _On, _- " approval - re than es z:ea.d e re broken_ -c -' - - - ---
ar Ot
=olcerl Pirefs are ren!lcee
QOstPdctlOIl is r`moved
�•�explain: �
Pa2e 3 of l 1
OFHCI,L INSPECTION FORM- NOT FOR VOL_U_-_N_T--kR__'-7 ASSESSMENTS
SUBSURFACE SEA ALOE DISPOS.-kL SV&TEA1.T_,vsP��ric��
PST A
nCERTIFICATION' (conti-�ued)
Property Address: A
,6�P
Owner:��h_CO
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in or et-to Bete-
is failing to protect public health, safety or the emdron--nent.
1. Systerr_-,ill pass unless Board of Health deterrrunes=n accordance orb 323 C:1
IR I5wC3i_=) n)that the
system is not functioning in a manner n-lr*ch will protect public health, safety .nd the eriviron-ment:
CeSS 00%it p i�-_s ``im�C'I et of a surf
ace ace aieI
— Cesspool or prsy i5 a:hire 50 feet of a bordering vegetated wetland or a salt marsh
3. System w'iii fyii illness the Board of Health(and Public eater Supplier,if at-=,,) de-'-miirfes that the
system is sunc.-oninff in a Mlanner that-protects the u f un - y
_ public health,sa<etti a<.d et- -i,o;lment.
Ti-le s;;ster-:has a septic tan' d s '7 bs '
1 and or_a��o p ca stistem(SAS)amid th-SAS v -_ _ '_0G' c a
surface w%ater supply or tn-bu al-v to a surface water supply.
— T—',e sy tel_L-as a septic tzm'K and.SAS and h S - _
SA,.,;s t`iK _Zone i L_a i1 '_;: .:C�.C"-^2
e system has a septic tank and SAS and the SAS is within 5E3 f -feet O_ a private water S"CID,
The system has a septic tank and SAS and the SAS is less tna; 140 Pet b:Lit;n feet et-more o_u a
private water supply well`*. Method used to determine distance
**This System paSS25 if the well water analysis,perfo__=ed at a DEP cer`=Led l
a-b to:
:- =0=COI=_Qz-':'
bacteria and volatile orga:dc corwounds indicates t:_at t'ie well-<free ue` �cii._lo--om-+at f$C'iii a u
pie preSeP.ce of arr nonia nir•ogen and nitsale=1'—_O_
c� -Is eGuc O Or' Cc
fai_ure Ti`e 2 ire . ereC. i a e .L_a
cov Ofth aIl2lycls..ust, be 2,,'achncd .O �
3. Other:
�,
f
OFFICIAL INSPECTION FORAM—NOT FOR VOLUNTARY ASSESS1fE_i S
SUBS I-REACE SEXY AGE DISPOS_-#L SYSTEI-I INSPFCTIOZ rOli-Zr
PART A
CERTIFICATION(contmhued)
`y / /✓ fJ
Prope �, Address: � �c, j
O«-ner: G �So7
Date of Inspection: S O
D. System Failure Criteria applicable to all systems:
You, must u'.d:cate `yes"Or''zo"to each of zhne f0i Cw ry for all:nSpeC'
Yes 'No
Bac lan of se','a' Div w f'_ Cr c;rc;e CO'yn Lt&Lje _C iloadc:d c- 0. CO`
�Disclarge or <ondmq of e�;rent to the Sur ace of:tie wound or surface vv' a- �•erlo '��ce at_�_ due to a- � ea�e�or
c ogled SAS or cesspool
StatiC liC-1`d level iIl the GiSiTibU ion box a}1Cye cutlet ue-� o,_ ?Or� d c, an .Ca•,. _ bace C_zS Or
�e2ss-'001 -
_ t/ q ii de_`� cesspool .s less t`a E' below ,v: Cr ava ab C7�c =e55 btu ' G�cL
l Required pu-ing snore than 4 lanes in the last-year_NOT'due c clozzed Cr o s�cted r_`(=1 V1��-_ er
�6f tisnes purrped
y porL-on of the he SAS.cesspool or privz.s w ig ar^ elevation -
� Belo' rL�.� o:ud water .
pc 'C_CrCeSSL'•'JC!0 7, is%xitt:i 100,-tt of a Stl?aCe Faze'sur-op or in'b tar—% `_O a SLiace
�w2ter supply.
A_nv portion_of a cesspool or privy is vit_m a Zone I of a nublic wrell.
portion of a cesspool or privy is within 50 feet of a private water su-_"_It-well.
v Any pion of a cesspool or o=itiz s less than 100 feet but heater than 50 eel=ors a private rater
po
supply well z"ith no acceptable water quality analysis. fThis 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 azninonia
nitroger, a;.d :nitrate nitrogen is equal to or Iess than 5 npm.provzded that-o otber failure criteria
are triggered. A copy of the analysis must be attached to this form.;
�(`fS/ C) The 5 "Ste272 falls.<;ave deter, ned that one or more of the aboveC?i+S-25
described i 3 I0 CAR l . 0�.therefore the Svstem fails.7,he sys eln owner should ccn'ac''ie Boar
d,oz
Health to determine what h%iil be necessar'to Correct the failure..
E. Larae Systems:
To be considered a large system the s=stem rrust sere a fac-liti witlt'a des au flow of 10.0n0 =pd 5.C.of)
?p d.
Yoti mu s:.n,G_caie e.Liie. •;es Or _o 0 each C^:ale.otcC.i'
ri
The icli0�% -1g _iter:a a =Iy to . 'G'',=,;i di to the
i.ad�t_CL
-he S,ste.n 1. w..11__. 100 feet Of a Sum--aCe C ZIr.Gi: '.:aZ!7 L t'
-,_e S,Stem is wit! , . 200 feet of a iribuiary to a sarface drii- 2 slate__aup1_y
'Le SySL r_n_s i� catea_in a nitrogen sere tiv� _ T - .'� > h - - -- -
- a. are_ ,al=- _,- zac' a c-ecr
/-one :.1 Ofa r u, i`c waier S pp vel! - --
CL• ..mot. a S iT:ereG - eS' ' ail,`0u25aJ n. _C2C On L -cte. is -
i':S ! Je�':CP, lj °nC�'e ire iar_e : cse� as fa le4. ' -
C Tea'.n yer S-Cti ._=o r t 1 e d
Gi cz l a:.0 cP7-- t `:cnai-off-ice
OFFICIAL E SPECTIO--N-, FOR_NI—NOT FOR`"0LUNT-AIRY ASSESSZZEN TS
SUBSURFACE SEW_ GF DISPOS-I- w TENTI SPECT•ION FQRNr
PART B
6,�CHECXLIVST
Property Address: O� G,-k<00
Owner: G (�S'v
Date of InspectiGL: O�
C ec's if the follow—irz;:ave peen done. You must indicate`•ves' or"ilo"as tG eac h of_ice To
C«-_c
�.
�Pti�ing r ormation was provided by the o«?ier, occrpart, or Board of Dealt
v ��i ere any of the system co rnonents pumped out in the-ple ous two a ee-?
Has the system received normal flows in the previc-as mo wee{period?
"--Have large volumes.of ester been int od'uced to the sv Stem recenid 'or as Dal L of this
/ y "S'JeC`G
t/ ere as built J:cIlS Of iPe SI si27 Cbtalined and e ami�e���1i LEti we_-not a 'a;<3�'e note a5 N
r/ Was the facility or d«•e-Ring iispected for si_�cf sew'ace'iack up
V-gas:-he Site i_S-)ected for siai,S of break out
, ere all system colmponents_excluding the SAS. located on site
+ye'z me se-odic tank.ma leS ii•2COVe7�d. Owe led. 2^r ire u_ic�C_C2 d e`�Ttti �C f0 :Le C C-Gu
of die baffles or tees, rnateial of cons nun on,di nension-s. depth Or__ id, ae•-;u Cf_l;_;_ee __`de-th C-sc'UM .
Was _he facility owner(and occliz)aPis if differert f om own - `mot L,;-ft y-Gr^ - -
ei ur Zd2C le _ �cc_C G e'.e
i*!aLlTenance of subsurface sewage disposal sy stems
The size and ICCatiOn of the Soil AbsorptionISystem(SAS)or the site has gee- det_- wed ha ed or:
/e_ �x;S`,ncri in
fnT'7a:1G^_. FGL ? ale ? +
X . n lal c l e:^Came c -le Q,:.`l.. -
�' _ is a - ___..;�_.__ _ _:S
-.,t_3acc !aV e; lint' C1'.R 1�.�.,_( ll I_ -_C..
?agae 6 c`i i
OFFICLAL I1NSPECTIOo FORM--NOT FOR VOLUNT.-RY ASSESS--�IE\TS
SUBSURFACE SCE SE«'_AGE DISPOSAL.SYSTEZI INSPECTIO FOR-:1-i
A.RT C
SYSTEM ENFOR.lFATIO
Property address:
Owner: ` G, JSo-1
Date of Inspection: $� o
FLONN�CO`DITiO-N-S
RESIDENTIAL, ^�
~ibzr cf bedroo=,ns �deSign): .S 1,_, rb
_ ber of bed lac jal:
D ZE ST GN Clow based on`10 CM/1 55.20-3 (`Or example: i 110 apd",=oi'Ce0_;.o0',i. ��a
\umber of cu rrent residents
Does residence have a<zarbaae grinder(yes or no):/v0
is laundry on a separate sew-age syster7( or ro):� �<;Les separate;nspec_cn regl_ ed
Laundry system.inspected(yes or no):ZY
Seasonal use: (yes or no): /1/4
Water meter readm,,s. if available(last 2 years usage
Surnp pL'^lp(yes Or no)•
Last date of OCCi?pa?Cy: CN//(✓
CONnIERCIAL/1-ND STRIAL
Type of establishment:
Design flow(based or?10 C R l5.20 ): rd
Basis of desim flow (seatS;perso.s,'sq-.e c.):
Grease tray present(yes or no):
Ir_dustrial waste Folding tank present(yes or no):—
\on-sanitary waste discharged to the Title systzr?Ives or rc):_
Water miete;71adintrs_ i=Fa-ailab11e:
Last date ofr
occur;arcy/use:
OTHER(describe):
GE\-ERAL L'NTORMATIO
Pimping Records
Source of infor-�.aron:
system pined as part of the inspecii• ;zs or no):410
lfyes volume pun-ped: call_ons ---Tm :ia5 v - �-�� e'
Reason for puurlpinz ~yam met---
TIC F SY STEti1
_Septic ta_1k, dist-±bu furl box. soil absorpiion Svste-.
—Sin?Ie cesspool
—Overflow'cesspool
_ O_ _. i " yes, auaCr'p-e.i015 i 1 _"i0n rcCOrt S.
i O'
tllclran
0'07`i At`ac a Co') 0
JCi aL:.e(.. `,o s�'\le
__ l'.��.,`_ _C.ik tmc,"- a cop, o_ t1l, DLL. alJ r� _
7 O ai
C.ber(desrioe1:
:�LOiO:llil Lazo aye C1 al:Com -nr
pone;1 at 11��:411� Its:Q!o- a C l-
d aur.e of
rr se.,are cdc-s tzc'.d
pure _or- '
OFFICIAL INSPECTION FORLig-NOT FOR VOLU T_-43..RY_ASSESS-A ENTS
SUBSURFACE SEWAGE DISPOs-iLL SYSTENTINSPEcTIO` FOR-Nf
PART C
S A'STEM INFORMATION(contmuied)
Property address:
Ojz ner: CS'! "✓_ "�
Date of inspection: -�
BUILDING SENZER(locate on site plan)
Dep`Lr below-grader
Materials of censt-uc`or::_e.Ca;t;;on PVC_otjer(exLiainn):
Distance om ririvate water su^piv w'eii or suction line:
�O:i en�5(On condi_ion of Q:711ts. v�j'1t7 /` evidence o ' '•
J s eaicage; etc.
j.
SEPTIC TANK_""ocate on site;:ian)
Depth below•grade: lJt
Material of cons-trJction:_ oncrete_metal_fbe-glass_polye`n;riene
II tank is"..Lai ist age: is ap con1L"?ed Lti r, r i e
a�.c'_ iflcate o2�.C�p�d (yes o_ ..',o? , -aC=2
erdil
Dimensions:
Sludge depth: of
Distance from tot; of sludge to bottom of outlet tee or bafe: 31D
Scum thic'imess:less / " /
Distance frees top of sc;r to top o`oitizt tee or ba Ile: b
Distance 7Fom bottom of scum to botrom,�r �tiet tee or bare:
How were dimensions deter -nee?: / o�{ R44 Cr
.."LZ:C Jt Uaiile�:Gi,'.,.-Gu. `;i l..L
_ C
aWlated to outlet in e_ , e-videi e of leaka=e;
!°� e L a
GREASE TRAP:/I/(locate on site Evan)
Depth below-grade:
C7 Coi STL1CuGu: CGi Clete eLai
(ex',alil):pl
v J
Dii`ieuSeC�:
Dista ,-e tc ^rsC•:�._. LG LG CI of lel. or mz=
D.Cl!L �r li%'ttGil.�.:lt.da LC b07-G:i�G_G1 Ie`Date o tee.Q
f ias� J:11r
L =e7lCi" Lt _ :Ga C+DT :' to S. L anal v . C _ __
-
o e _ -
Pa oC 4 c T
OFFICIAL INSPE CTI 1 OR_I NOT FOR VOL6T IR'I _kSSESSZrENTS
SUBSUR-FACE SE eNAGE DISPOSAL SY STINT INSP;=I~TI ti F4?2ZI
P:-.RT C
,pp /S�nYsSTEM INFO NLAT ION rco -!Lned)
Property address: O� . 492 � 6Z►4r— A-11
0o,::er: G�dy'p-7
Date of Irispectior.: S Q
TJ(-THT nr TTOT_DTN(--r a r-u:
t
De-:hbelowgrade:
tV;a.erl8i Cf CO st ic`C:i: corcTere metal `:��er�i3SS. poilve Ilc' Q_e'i e t`'a,. i
Dimensions:
Capacity: capon;
Desigi:Flew: ------,----}-o , .
allons,`dav
Alarm present(yes or r_o;:
Alain level: Al arm;n 07 Vie-(<<eS or-C�
Date of last psrr-pmg: _
CO=entS (Condition Ct a:a.=and float switches, etc.):
DISTRIBUTION BOX: C" f:zes.Lt m:st be ,petea)(iocate eT s..e"Dian)
De^'q of':a k:d 'eve,ac, -o_ le u'ivert: ✓70/'v"te., u
CJ^itertiS (LOtc ;i)0r t 2t aLC osSti vI+;,m,i0 Oiiu :euLaL az,e'vtGence of-�O s op=—:over.:any o
leakage ir,_t�jcr out a io,
/J O ye
PT--"IP CHA-MBER:/y (Iocate*or,site.plan)
P-L:.-rtps in working order(y''s or rye;:.
Alar=, in}vo t mg order(ties or no):
CO iitT en S.(i Ote ccInd _ion p=.:nip Clamber. condii on of pI�e'0S a Cap �t nances etc._
,.
f
?ale 9 of i
OFFICIAL I SPECTIO- FORM—NOT FOR vOLIN-'.ARC'ASSESS1IENTS
SUBSURFACE SENVAGE DISPOSA-L SYSTEM rSPECTIO FOR*-I
PART C
SYSTEM INFORMATION(condmied)
Property Address:
Owrer:
Date of Inspection: S 0
SOIL.ABSORPTION SYSTEM (SAS): (locate do site plan.excavation not required)
if SAS no located explain:vhv:
eact=a pits;nurrber:
leaching chambers.n ruler: 11-1jo
leac_..ing Galleries, number.
leaching Uenches, number, lengti:
__'each ng fields, number di_~ensiens-
overfow Cesspool. number:
C"vatiz: ."al.c uaii'%2 _ Stem i;-peilia_:_co=tecind"Cw:
Corr�•_lertS (note condition. C.sm-L si-i'L of h draialic :l ie.levei ofponr%..ng.da= soli, ConCitiion of =2 2-81CIl
etc.):
HS O� /q✓. /.G �' y/c�
CWL
CESSPOOLS:/y (Cesspool must be pumped as pail of mnspeCtioni(locate on
uaii l- and COTlii ulatlCIl:
Depth—top of liquid to irdet iIlveit:
Depth of solids laver:
Depth of scum laver:
Dimensions of cesspooi:
Materials of cons`,det on:
L dicaiion of ground,. ater inflow(yes or no):
l-ornxnenl_ (note condition of soil sighs of �'d ,. ., a ievei r n -. - - --`Lt 'a ill Iai_ii _ ,OI�,O CiIl �- . .
PRB-Y:/�/ (locate on site plat)
_at_^ais cf cers: i do
C-r_mean mote Conn c c: vrs ;cam: n' r; i' r2 of,
Pate i V Or!
OFFICIAL INSPECTION FOR -W-NOT FOR VOL€,`NT-kRY ASSESSIIENTS
SI`RSL.-RE-'SCE SEt�;.-kGE DISPOSAL SYSTEM I--N-SpEcTro- FOxNI
PART C
SYSTEN'FINFORAL-kTIONicoy Le`i
Property address: O �
Date of Inspection: p
SKETCH OF SEV'VAGE DISPOSAL SYSTEM
sketch e't:e oszl _:s.ewi _ld c es to -'e -
e-ch-tea-is Loc a .. :C'G;fee-. Locate -sere uubli: ..ate:
,� Fr0•�T
i
l
a�
I
f:,.o
of _
OFFICIAL INSPECTION FORM-- OT FOR VOLU-N.T-AIRY ASSESSAfENTS
SUBSUR-FACE SFWAGE DISPOSAL SYSTEM F SPV CT-f0N rpR-Ab
PART C
S Y'STFIN'i n-FOR LATIO tcon ed;'
Property-Address: iel )2d
Owner: SOil
Date of Inspection: S B
SITE EXA--I
Se e
Surface water
C^eck c iia-
Shaiiov,-weiis
Estimated depth to gm,-,nd water�SO feet /V Ile-&A 0-1 F 4, /Jm�
Please .nd-,caT (check all me' o'ds used to defer=c ire Slplu go2l n.,d water eleva-on:
Obtzi ed F om s s: _._desigza piar_s on record-'f checked date of desir_:
O
w r::ii•crl .� -1�• C. .c '.vi F:u��; __.i y _'C f��_ T �'1✓
ruzcked-.Ofth ioca:Bo__C. of_'3ea_ ' emolain: �(ti
Checked-with local etca a ars. ir:stai_'ers-,a Laclh docu me i2`:CIlj
Accessed LSGS database-exoiain
You must describe'/ow you es/`i�abiished Tile fit rh around iva er eie-vation:
Pf� /70� /KPJv�/7�l �0c,w /1/O /oti� �wr.�e✓ ,4 IS,66"•
Z& �o� o c D e ot,, 1.
4,1
,Ce --
24 ��S
o
N
lip
r Ey
t.flj ;-
rn
�03
44 !
� >V4?J
CA� c
�oR�
T
f
r�� t
uY
1% Ire
42 Z 42•m
N - .
l!o' o I S T..5cK
43 , Z 42.85 enolooe
loFt•_Dw�t.
i (OD OC�aI• 2.4. ebb Cow s•L.s Ac.l4w Pir
e A p a
Sepfic_ TavA k
AA6
Aea
�- 36,O A AA
`�` tih BoT F, F�Ey
4�o 4-''
44�5 43 , IS2GoT� oN �AT�: 2M�}� �»vc�,I DRoQ
TEST gn.;zCORMEv Pro 2-S
BEDRooms K IlO GPD = 3pGiPD AcNit�C,
C-�ARaac.e DrsoosAL I�SE 100 o CAL-SE
CAPAC- Ty PR o\J tD E�D ;
q-a,o
Tl"!r-) x ( x ?-, 5 = 471,ZC--PP
TOTA'!- CA FAGITy PR6V P 7 G45,7GPI? .
t5POSAL- S`/STE-M D s ltgt�t I
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Town of Barnstable
�t41E Tp�
Regulatory Services
saxrvsrastE Thomas F. Geiler,Director
v Mass. �
$ 16=9. Public Health Division
ArFD��A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
aI _ a�
flayst *S
LOCATION 1 5EWAGE PERMIT NO.
VILLAGE
0�,n
INSTA LLER'S NAME i ADDRESS
6 Ub 1 l 0 E R OR OWN ER
oft
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��
L
CA- �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TowtJ... ..............OF ... 04).S..T APSUL
�\ �-0AI'VUration -for €_gVagal Works Tvit,itrurttiiaa Vrrmft
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at: „
ocation-Addr ss or L t N
C R��, . �a� --•---•-------------------------- --- a-q Q.�- -1�a, -1� �� � -...#--
Owner Add ssIt
a _
In taller Address
dType of Building Size Lot__:+f30_0____-Sq. feet
U Dwellin No. of Bedrooms.________. -___Ex Expansion Attic Garbage Grinder
g P ( ) g ( )
aOther—Type of Building ____________________________ No. of persons._________-__________-_-__- Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------------------------------
W Design Flow.._._......!5�5..........................gallons per person $er day. Total daily flow___..____....._.~ _6-------------gallon..
WSeptic Tank—Liquid capacity-1.Q0Qgalions Length_�_�_fa__`�_ Width._4!7- 0.. Diameter"74__-___. Deptli.S__-4-...
x Disposal Trench—No. .................... �l�id hf...______a________. Total Length-------------------- Total leaching are a____._______._.-----sq. ft.
Seepage Pit No........I........._.. Diameter_ ._"..()-_-_ Depth below inlet__.__-.-.0... Total leacllillg ttre l - _7-_-.___sq. it.
Z Other Distribution box (15 Dosing tank �j )
~" Percolation Test Results Performed by._---.�.fi r- --� 1:!!� ---`----------------- Date...Av.i---za.tcm.o /
Test Pit No. 1....:Z�------minutes per inch Depth of Test (_. Depth to ground water.)W_ _ _1COV"?-kr, A
Gz, Test Pit No. 2......Z.:...minutes per inch Depth of Test Pit._13..."®... Depth to ground water.i a_r--- l�
aa� --------• -- ----------------- •..... . •. ---- ---------------•-•---...---
x De c iption of Soil__..`. e--�4'#-.-- iY��i�t / 0----40 - .G¢�. -
V ® / �G.t_.� ��e� �°��� S �-------------- -------------------------- ----
W -----
--------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------___________________..
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T�u f(cc S 54of the State Enw i Y Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sue y t e board of h lth.
Ai
Signed.__... -- `- ------ ------ - -----------------
Application Approved By---- - �' _
------------------------------------------------------------------------------- ..................
Application Disapprov r tl following reasons:................................................................................................................
-----------------------------•----------------------------------=--••....----------------•-•--••-----.....•••--••----•-•-------------•--•-----•-•--•----•--•-----•-----------•••-•-----------------------
Date
PermitNo......................................................... Issued.......................................................
Date
No......................... Figs.. d..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HEALTH
TOw&.), ..` OF._. �A; l�1S7'A. .Lt .
A.ppliratinrat -for :Dhipoii al Works Toatitraartioat Vrrntit
Application is hereby made for a Permit to Construct,(,Q or Repair ( ) an Individual Sewage Disposal
System at:
.......................... ► _ei y--. 1 1' .............................. ............ •--------- ---
' ocan-Add e-i � or No
�v•-••• -----•--------------------- 5� WG -OA. r�
W Owner , Addr�s
G� In aller Address
Type of Building Size Lot__ZQ°s ----Sq. feet
Dwelling—No. of Bedrooms----------- _________.___--Expansion Attic ( ) Garbage Grinder ( )
pi Other—Type of Building ____________________________ No. of persons.---------------------------- Showers ( ) — Cafeteria ( )
a
... ¢ Other fixtures ----------------•---------------------------•-•-•-----------------------•------------------------------------:------------------------•--•--......_..
W Design Flow.._... . _J........................gallons per person per day. Total daily flow..... __��.�_._._:.... -7 gallons.
WSeptic Tank—Liquid capacity_L1 0-Pgallons Length.8'�'__ 1/Vidth_.4.-.-/O._ Diameter ___ Depth.�_'.4.. .
x Disposal Trench—No_____________________ ��/id ht__-_______ _______. Total Length___________ . Total leaching area_._..__._____.____-sq. tt.
r //� -----"
Seepage Pit No._______�_____:______ Diameter_ _ _....Q.:__ Depth below inlet____ Total leaching area 2t��7_____-_sq. it.
z Other Distribution box ( V/ Dosing tank � ) ((- nn �_ , -
Percolation Test Results Performed by------- -:.___10._ 4.!�`_ahl— -------------------- Date_-_tt�_ .Za .t_5$a/
Test Pit No. 1____.�-__-___minutes per inch Depth of Test Pit... Depth to ground water.NpTf�-h-Cgun�fkr d
f= Test Pit No. 2......:L....minutes per inch Depth of Test Pit___ __ ____ ____Depth to ground water._�'1a.l--�'!'t �� �
--------'Ii--- ----------'.----------- ------------ ._.r._ ----------- _-•'---
0 Description of Soil--0 /$ LQl 11 . ^Lt. �� �'Q '"rI'1 .E,�Gr�_
W
U Nature of Repairs or Alterations—Answer when applicable......_-----------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions ofjv! a=5 of the State f e2 Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed-- -----•--• ------ ------------ --- _. D--e---------------
aa----------------
c ApprovApplia ed YE J �
Application Disapprov �dj r tl following reasons:---------•.............................•--•--._........-•-•--------------...........-•---.....-----•--------•--
•--•-•--•-•-•--•-•--••---•----••---•................••---------••---.._...--------•--._...-•--••-•-------•---------•-------------•---•-------------•------------•--------------------------•-------•----
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS ~
BOAR OF HE LT
,eta. ......................O F.................. .:... . ........................................................
(Irrtifirate of WlImp attrr
T ZS`I r ,-That the Ind' ual Sewage ^Disposal System constructed ( �r Repaired ( )
Yl/1
by.........r.,. .....--•=-•...-•---- ••.. ... .� - �",`-------------------------------------------------------------------•----------•-
Installer
--------A ' ..... ..
has been installe49 in accordance with the provisions of _Awticle XI of The State Sanitary Co,(y a#/described in the
application for Disposal Works Construction Permit No f._� ' ................. dated-_ /�.M.__._.._....._.._........
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI TORY.
7
DATE..................................... _ '..•........ inspector.............................. ------ '
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HE. LT 0'
r 1. Ya.g............... ...... . OF F11ft -
No.f�:::. .. .... FEE..,I A..............
DiriVn ii ur = o tru 41n rrmit
Permission is hereby granted...... �--------------!'--------------- --- -- ------------ - ------- `-'------ ..................................................
' to Construc or Repair ( ) an Indivi 1 Sew I�` posal
at No - L4� R3' ` `
G --•-
Street
as shown on the application for Disposal Works Construction Per ._ 1' ' .... Dated__ _fir._. '..................
-------------- ---- -------------------------------------------------------------•-
G/� , �Dd� Board of Health
DATE.-------•. .. ...... ........... .... .... //
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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