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0005 CRYSTAL RIDGE ROAD - Health
5 CRYSTAL.RIDGE P ,y , No. L()2 1 7 I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y ftpliLation for Bispo8al 6pstem Construction Permit Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S Cf IsH 'K'C�C Owner's Name,Address,and Tel.No. Assesso�p/Parcel ©e& "®Q" --© 3 'cc I M C Vtf-, Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. iBailm 400c. 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) L I 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 Bo igne�L Date Application Approved by Date _ 2 Application Disapproved by Date for the following reasons Permit No. 1 7�U Date Issued No. 20 2 r �V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yew 01pplication for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S Cf Nf 5 1�c 12� Owner's Name,Address,and Tel.No. Assessor's map/Parcel (�� 06g—0 fl/1� � •�I Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: 'Dwelling No.of Bedrooms p 11/,� Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildingp /�/� No.of Persons" r Showers( Cafeteria( ); Other Fixtures Design Flow(min`required) �j I+ gpd Design flow provided & I a 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 th�azd-of-Health. Date // , 2/ Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Jc4 1 - V/0 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( )by �,1,-�4 A I\J(Cj!wro T,�C at ; r 4 it k.,1 c,��C' 1< I� rC� c�1'r has been constructed in accordance 7 ! V 1J with the provisions of Title 5 and the for Disposal System Construction Permit No. ).).2 LI/Odatedell I / Installer Designer N 1\ #bedrooms Approved design flo j 4N gpd The issuance of this pe it shall not be construed as a guarantee that the system wiIT/ lion as design, . Date � T1 �-i Inspector �j t. c � _- - - - - --- - - - - - - ---- --- No 0'� T 0: Fee THE COMMONWEALTH OF MASSACHUSETTS N PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal &pstem Construction Permit Permission is hereby granted to Construct( ) Repair(v) Upgrade( ) Abandon( ). System located at (rt(�!S fit'.. �`�Cf f �/ 0 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:Consuctio�. must be completed within three years of the date of this pe ut. Date I//'M_ 1202— r Approved by r Y: h No...9 L.__ 23 FFz THE COMMONWEALTH OF MASSACHUSETTS v �J -� ),B/OARD OF HEALTH ........ /..1/L�!.M..........OF............. Tl./ � i� .......--._. Appliration for Digpasal arks Tonstrurtion Permit Application is hereby made for a Permit to Construct) or Rnepair ( ) an Individual. Sewage Disposal System at-'- -�j•.�---........7.......................... .S`��c- � ....... cation•Ad ss .._... ........................................or LotNo.......................................... ................_... .._..'•--------•- ..... .... - ...._.._..........»....».»..._. Owner- �••---•- W - Address ,-a - 1 .._ Installer Address r Type of Building Size Lot_.. .f ...Sq. feet Dwelling—No. of Bedrooms................. Expansion Attic ( ) Garbage Grinder ( ) '3 Other—Type T e of Building No. of ersons____________________________ Showers Gv YP g ---------------•---••---...- P ( ) — Cafeteria ( ) a' Other fixtures ................ W Design Flow................... ------------- llons per pe a-per day. Total daily flow............Z,I'-1—f 0................ WSeptic Tank—Liquid capacity._ lops Length................ Width:..._;-____.._.. Diameter................ Depth................ x Disposal Trench—No- --------- --------- Width.................... Total Length.................... Total leaching area_--__...______-____.sq. ft. 3 Seepage Pit No.___.___A.-_.___ Diameter._�_�.__._.._... Depth below inlet.__. :e__ .. Total leaching area..4-..j' .0..sq. ft. Z Other Distribution box ( Dosing tank ( ) ' r �" Percolation Test Results Performed by....__..C.-- .l �%-....._.._,.ter................ Date__a..4..��.. .. ... a � r Test Pit No. 1________________minutes per inch Dept of Test Pit_...l� -__._. Depth to ground water.lLl.�._..�-.. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . 94 --•••.................:.... ............•-•---•----...........---•--............._..._____--•---•------...____---•-••---.........._'-•-..........._--_--. O Description of Soil... .___. _75`7 ------------- -*........... 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 LITAU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of health. Signed....... --••.................. .......:......... L G.........1..._. Application Approved By...... .._.. ate st1:,4< j:.:.�................................. D� -... r. Date Application Disapproved for the following reasons:............................................................................................................ .. ..........................•-- --_.....--------•.......-•---••- ..............................___--- ---__._..__...... Date.............. Permit No....... _ -• :;�,-•-••••-------------- Issued-.........-_-•--• ---•---___......_.................. � � �5 ,� •nave ........ •« Flms..... � .......... ,THE COMMONWEALTH OF MASSACHUSETTS �.. �J BOARD OF , H EALTH .....:. . ... oF.... ........ 1..a _C.&............ . Appliration for Diiipusal Workii Tonstrurtiun'itrrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: j—� Location-Add'ress r or Lot No. O ..................................................._.«...-. wner Address •.......................... ...=- -•-- _.. .............................................................. Installer Address _ Type of Building ,,/ Size Lot...C..S_� S--.Sq. feet a Dwelling—No. of Bedrooms.................... i............_...._.__.-Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q .,« -y,. Other fixtures . •--. •-••-- •--------•--------•.................••----....---•-••---...................__-•••---. W Design Flow........................��_...........gallons per pers�a-•per day. Total daily flow............q-.!�_(-.)................gallons. WSeptic Tank—Liquid capacity..l�1 411ons Length................ Width:............... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..........',k...... Diameter...!_ .._..... Depth below inlet....?.: ` ... Total leaching area.At.F?.12..sq. ft. Z Other Distribution box (5C)_ `"• R Dosing'tank ( ) / ~" Percolation Test Result Performed by....._.. '._.. '2 ..-. .................................. 'q �f C / a q _ Date. .....--•-----_--.:. a Test Pit No. 1................minutes per inch `Depth of Test Pit..../.-�6..... Depth to ground water..X �RVRVe . rX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ••--------••-••--•......_...--•--......-•-•-----•••----•--•••..:...........•---...-•••-••--••--•-•--......................................................... O Description of Soil..,- �r......_..... ...............•------••-------_---------.- -------------•---•--------------- Vx ................................................................... ...................................�,.__...._.___..r-�•_.f__may .................•---........._..........__............._.._._....._............_._......._..........__............---.---.....:....._............_...................._................................. 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 TITL; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iisssued' by the board doff health. '` J Signed....._ '�✓±� r / !' d• �' o ....a• --- ..........t R.,/ Date 1 Application Approved By............. .... _!�. --C•/ ................. ... O � = �...... J q 5 Date Application Disapproved for the following reasons:............................................................................................................ -•--•-•-••--•................•-•-•--•---.............---•----............_.._.....--------...------......._......--•••---•---------.....--••-----•-•-----••-•----•---------------•-----.....---......... Permit No...... ^a ..................... Issued...........................................Date....... �• - S �• Date sos..r-a ----------- ----a.wrc.' .,.... ease Baar�N.�•^.arcmracrr•s....a....•.................... ..... a..T _.n-a-n>e-re-a a.o r.es.av+ow.s.o a,�c�..Fa• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF.-HEALTH G,!11.........OF........... .r (Irrtif iratr of Toutpliattrr a THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ,) or Repaired ) ......... ................by........ = ------•------•---•-•-•...............:.......... .................. Installer } at............. .� -= - . has been installed in accordancegvitli the provisions of`1TITLB j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......... �7__._79.--�S--- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. ^ -.0 `` Inspector.... r ....---•-----••----•-•_-•-- - ........................................... wwwwwww ..........i -------------- ......WAV.H.6�TF•M^.L•l•n n...y,wrn w.r w,.w.s win nw*1 r•R'wn Rd' THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH Q'C/ 'f `F No...................... FEE...2 ......... Disposal Works Tonutrurtion Fran t Permission is hereby granted...........ZT.., ............bence4g�k.................................................................................... to Construct (ac) or Relpair ( ) an Individual Sewage Disposal System at No........................i..r.. ..9..'._..���.�t.:�.r....��. t._..__�c�� � �r'1 V Street �p as shown on the application for Disposal Works Construction Permit No..�� ..... a� Dated_,-..................................... � L "Z"•"•.�, Board of Health ,r DATE • ---------------------- r ,, J OWN OF BARNSTABLE ®f #�/w7 n Cr �L� s (� LOCATION c-C�� 4 •7'`�/"�� ��t�5n ��, SEWAGE # I - J"), _ i 0 VILLAGE C40, ASSESSOR'S MAP & LOTdQ-461,613 INSTALLER'S NAME 6z PHONE NO. 10,10 SEPTIC TANK CAPACITY I,4-06 2a(jdy►S LEACHING FACILITY:(type) f i+� (sue) 000 5 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER bo"A.-v (d, 7-?1 '00 DATE PERMIT ISSUED: IZ/�� �a DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No j/' z e z9' 4 PjSCd& .1O.WN OF BARNSTABLELOCATION LQ-' 4 CS.jj j 0�;Jge Ck SEWAGE # /' - J'•, VILLAGE CoTJ. 'aI ASSESSOR'S MAP G LOT INSTALLER'S NAME G PHONE NO. lcyp SEPTIC TANK CAPACITY l,C' 6 LEACHING FACILITY:(type) Z GCAGL. Pi}S (size) Epp f al(ev%5 NO. OF BEDROOMS _PRIVATE WELL O PUBLIC WATER- j BUILDER OR OWNER bcxff'j, DATE PERMIT ISSUED: I Z/r1 `d9' DATE COMPLIANCE ISSUED__ VARIANCE GRANTED: Yes No f 1. Zg' k'b 3S�b a7' f i f COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVI.R.ONMENTAL PROTECTION E 1 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 'Property Address: A � Owner's Name Owner's Address: p/ Date of Inspection: ,n - Name of Inspector: lease print) IRK k/!0�`"`� n z� Company Name: Mailing Address: t Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I.am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: a ro p PP Y V Passes- Conditionally Passes Needs Furt r Evaluation by the Local Approving Authority Fails _.. Date: a'./W Inspector's Signature: The system inspector shall submit a copy of this inspection report to the-Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a.,shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the-,appropriate regional office of the DEP.The original should be sent to the system owner,and copies.sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection.and under the conditions of use at that time.This inspect►on'does not address how the system will perform.in fhe future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I r - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 12 Property Address: a Owne Date of Inspection: . Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D A. System Passes: �. I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements:If"not determined"please explain. The septic tank is metal and over 20 years.old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent: System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate.of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or,uneven distribution box. System will pass inspection if(with approval.of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 'Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Vie' -� Date of Inspection: Pf 0 C) C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order.to determine if the system . is failing to protect public health,-safety or the'environment: 1. System will pass unless Board of Health determines in accordance with 310.CMR 15.303(l)(b)that the system is not functioning ill a manner which Will protect public healthi Safety and the environment: _ Cesspool or privy is within-50 feet of a surface water Cesspool or privy is within 50 feet of a bordering'vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier;if any)determines that the system is functioning in a manner that protects the public health,safety and environment:. . _ The.system.has aseptic 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 SAS.and the SAS is within a Zone l of a public water supply. _ The system has a septic tank and SAS and the SAS"is within SO feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance - "This.system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;,provided that no,other failure criteria,are triggered.A copy of the analysis must be attached to this form. - 3. Other: 3 f - Page 4 of 11 - OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: cS` Owner. Date of Inspection: i D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: . Yes No/ _ 7/ Backup of sewage into facility or system component due to overloaded.or,clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool 1/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ 3/ Li uid de th in cess ool is less than 6"below.invert or available volume is less than %2.da flow q P P y Required pumping more than 4 times:in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ V V Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool:or privy is within 100 feet of a surface water supply or tributary to a surface / water supply,-.- . ., . Any portion of a cesspool or privy is within a Zone 1 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 I00,feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen-is equal to or:less than 5 ppm, provided that no other failure criteria ,��ll are triggered.A copy of the analysis mast be attached to this for /�(2 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to M 000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400-feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner shoul&contact the appropriate regional office of the.Department. . 4 . Page 5ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONTORM PART B CHECKLIST Property Address: Owner. Date of Inspection: 0 Check if the following have been done.You must indicate"yes"or"no"as to each-of the following: Yes ado Pumping,information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks T Has the system receivednormal flows in the previous two week period? Have large volumes of water been introduced to the system recently'or?as part of this inspection? L- _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)' Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? _�_ Were the septic tank manholes uncovered,•opened,and the interior of the tank inspected for the condition- of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum,,? Was the facility owner(and occupants if different.from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the.Soil Absorption System (SAS)on the site has been determined based on: Y 1/es/no Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL'INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ell Owne , '0 Date of Inspection: FLOW CONDITIONS RESIDENTIAL v Number of bedrooms(design): _ Number of bedrooms(actual): .`Y DESIGN flow based on 310 CMR 15.203.(for example: 1.10 gpd x#of bedrooms): T� Number of current residents: c2 Does residence have a garbage'grinder(yes or no): Is laundry on a separate sewage system(yes or nol://I� 4if yes separate inspection required) Laundry system inspected(yes or no): - % � Seasonal use: (yes or no):4�O_ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: _ _Mxz" COMMERCIAL/INDUSTRIAL ,fie' — Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the insp ction(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? _ Reason for um in : P P g TYP SYSTEM +_/Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be .obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): roximate age of all.com onen s,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):,ze 6 I Page 7 of I I OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION(continued) Property Address: Owne Date of Inspection:_ BUILDING SEWER(locate on site plan)Depth below below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): f SEPTIC TANK:i:::�(locate on site plan) Depth below grade: Material of construction: ncrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �(� • � ` �{ `j Sludge depth: - >� f> 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:_,3 Distance from bottom of scum to bottom f outlet tee or baffle: l� How were dimensions determined: Comments(on pumping recommendation ,inlet and outlet tee or baffle'condition, structural integrity, liquid1evels related to outlet invert,evidejice of leakage;etc.): — `5v /r GREASE TRAP;�Zd-(ocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee.or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:T Comments(on pumping recommendations,inlet and outlet tee or baffle condition;structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. 41 - . Date of Inspection: // .;)/ y TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: !✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal;any evidence of solids carryover;any evidence of leakage into or out of box,'etc.): �« PUMP CHAM cate 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.): 8 I ' ray,c 7 ul t i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE.DISPOSAL:SYSTEM INSPECTION:FORM PART'C SYSTEM'INFORMATION(continued)` Property Address: A Owner. , Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): locate on site Ian excavation not re wired <...: P q. If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition-of vegetation, etc -0- 6(go "A' ai3wz &aA ode4 CESSPOOLS Hcesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY�A�ocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: ' Owner. Date of Inspection: / e� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within]00 feet. Locate where public water supply enters he building. � -- � ID t 10 rage i t or i-i OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �� C.►` Owner. , Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked'with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: _ . 11 , -7. 7 -1-mom-M. 1Vare.i At JV O O Z.MUNJIUPAL WaTE-9Z evdll_o.PyuE t 3,P19e PIT(14. 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