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HomeMy WebLinkAbout0037 CRYSTAL RIDGE ROAD - Health 37 Crystal Ridge Road, Cotuit TOWN OF BARNSTABLE a:ATION 7 SEWAGE # VILLAGE ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No / o bQ, 34 Commonwealth of Massachusetts W Title 5 Official Inspection Form fSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted.on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information , on the computer, use only the tab 1. . Inspector: key to move your cursor-do not Carmen E Shay use the return key. Name of Inspector Shay Environmental Services, Inc. Company Name 185 Ashumet Road _ Company Address Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification �_,! I certify that I have personally inspected the sewage disposal system at this address and that thee- information reported below is true, accurate and complete as of the time of the,.iris.pection.The inspection was performed based on my training and experience in the proper function and'rriaintenanbd 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: ® Passes ❑ Conditionally Passes ❑ Fails s,,a1 ❑ Needs , urthen valu tic, t e Local Approving Authority 11/1/10 lnspe or's Signature Date The s tern 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. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 37 Crystal Ridge Road,Cotuit•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Vie 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: 2 leach pits present. Both had No liquid-4' effective depth available in Both Pits per stain line. Risers present on both pits. 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 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: f ❑ 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: 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(1)(b)that the system is not functioning in a manner which will protect public health, 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 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 SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. 37 Crystal Ridge Road,Cotuit•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address 'Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes . No ❑ ® 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 100 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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 should contact the appropriate regional office of the Department. I 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ 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? ® ❑ Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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: ® ❑ 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(5)] 37 Crystal Ridge Road,Cotuit-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 vcl 2c\ �o CLCc VV--V Q6,C�,� 549.7 gpd DESIGN flow based on 310'CMR 15.203 for example: 110 gpd x#of bedrooms): per plan/pit Number of current residents: fir Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: August-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): -- 37 Crystal Ridge Road,Cotuit•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board.of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1989 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ p 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbingproperly p operly vented Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 6' x 10' - 1000 gallon Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is Cotuit MA 02649 11/1/10 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in,good condition,lnlet Tee in good condition, outlet Tee in good condition Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity. gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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.): Liquid level equal to both outlet inverts. No significant evidence o f solids carryover. D-Box in fair condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-6'diam x 6' D ❑ 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.): 2 leach pits present. Both had No liquid-4' effective depth available in Both Pits per stain line. Risers present on both pits. 2 leach pits are designed for 549.7 gallons per day per leach pit for 1099.4 gallons per day total. 550 gallons per day needed for for bedrooms with a garbage grinder. 37 Crystal Ridge Road,Coluit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool 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 ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate 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.): 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments j. 37 CrVstat Ridge Road Property Address Howard $ Jaynee Budovsky ----—-- —---------- Owner Owner's Name information is MA 02649 11/1/10 required for every Cotuit ------- . ........ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal Systern: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0 C. -34 37 Crystal Ridge Road,Coluit•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 t� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Crystal Ridge Road Property Address Howard $ Jaynee Budovsky Owner Owner's Name information is required for every Cotuit MA 02649 11/1/10. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 15 feet feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: El Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain.- You must describe how you established the high ground water elevation: Inspector has performed perc tests in the area. x 37 Crystal Ridge Road,Cotuit•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOC ON 3 2 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME 6i PHONE NO. A & B CANW 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(Cype) (size) NO. OFF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes No II �1 q` / o o v http://issgl2/intranet/propdata/prebuilt.aspx?mappar=056002015&seq=1 3/30/2012 COMMONWEALTH OF MASSACHUSETTS S T EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROT I'ON ONE WINTER STREET. BOSTON. NIA 02108 61 292-550 WILLIAFI F.WELD a TRU COXE rn Jry 9 Govco! 350 MAIN STREET r' y OFq 1 9 l � crctan ARGEO PAUL CELLUCCI WEST YARMOUTH, MA q�TNggnSr�eCf DAV B TRLINS Lt.Govemor O 508-775-2800 missioncr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO S PART A CERTIFICATION PROPERTY ADDRESS: 37 Crystal Ridge Road, Cotuit ADDRESS OF OWNER: DATE OF INSPECTION: October 13, 1997 Carol Julius NAME OF INSPECTOR : James D. Sears I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A& B Canco MAILING ADDRESS: 350 Main Street, West Yarmouth, MA 02673 TELEPHONE NUMBER: (508) 775-2800 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: October 13, 1997 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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 b the Board of Health, will pass. .Indicate yes, no, or not determined (Y, N, or NO). 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 is 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. Page 1 of 10 (revised 04/25/97) DEP on the World Wide Web:hftp://www.magnet.state.ma.un/d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A 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 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 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 APPROPRIATE) 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 to 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 1 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER I (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 37 Crystal Ridge Road,Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 D] SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: N/A I have determined that the system violates one or more of the following failure criteria as defined in 3110 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 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 over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped 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 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: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: N/A 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 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. f (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health. X 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site. X 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: X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information. Ex. Plan at B.O.H. X 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)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 2 Garbage grinder(yes or no): YES Laundry connected to system es or no): YES Seasonal use(yes or no) NO Water meter readings, if available(last two(2)year usage(gpd): 1995-96 65,000/ 1994-95 54,000 Sump Pump(yes or no): NO COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day 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: N/A System pumped as part of inspection:(yes or no) NO If yes, volume pumped: gallons Reason for pumping TYPE OF SYSTEM X 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 1989 PERMIT#89-212 Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) •a Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: X (Locate on site plan) Depth below grade: 20" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: ill,— Distance from bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined ASBUILT&TAPE MEASURE 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.) TANK AT WORING LEVEL, OUTLET BAFFLE COVER 20" BELOW GRADE. GREASE TRAP: N/A (locate 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: 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.) I (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 TIGHT OR HOLDING TANK: N/A (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: Design flow: gallons/day 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: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc,) D-BOX IS 16" X 16" 30" BELOW GRADE, BOX IS CLEAN AND LEVEL, ONE LINE IN,TWO LINES OUT PUMP CHAMBER: N/A (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 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 2 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, condition of vegetation, etc.) TWO(2) 1,000 GALLON BOTH PITS ARE PRE CAST, PIT(1)40" BELOW GRADE, COVER 20" BELOW GRADE WITH WATER. PIT(2)40" BELOW GRADE 20"TO THE COVER 18"WATER CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil, signs of hydraulic failure, , level of ponding, condition of vegetation, etc.) i i PRIVY: N/A (locate 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Caron Date of Inspection: October 13, 1997 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) � O dq' 3G ss " �y o � (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Crystal Ridge Road, Cotuit Owner: Julius, Carol Date of Inspection: October 13, 1997 Depth to groundwater 48.2 feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained fro Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) WELL DATA SDW 253 ZONE E (revised 04/25/97) Page 10 of 10 _ 4 l Sao Lj Ge,L. l L4"ss (i ,CZ i Lr P �v Shot E. • V.%oY �a� � �f EL';��7�� i �P(1G -1"eN K � — S.: z r_ . GPpII' ` u coos~ EA4-t4 PiT t. �O.EFF p►at-� X Gam' ELF �6P`C�4 , �� t A t , �77T41 g. `i " � V. 4 ��of ►�,�-C�. . .. ; : , � T cam', �Qa�E J TOWN OF BARNSTABLE LOCUTION L-O I I C ty 5'�� !��c�j p I�,cl,SEWAGE # VILLAGE L O4'j V _ ASSESSOR'S MAP LOT ✓�� 2''dO INSTALLER'S NAME PRONE NO. �`� ' pt�sca -2 71 - 10 q o SEPTIC TANK CAPACITY LEACHING FACILITY:(rgpe) Z b<mc ` S (size) ` �. e -c . NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �`L�5 1 ,0 DATE PERMIT ISSUED: - — DATE COMPLIANCE ISSUED: �S - VARIANCE GRANTED: Yes No �/ 49 M THE COMMONWEALTH OF MASSACHUSETTS BOARD - OF HEALTH �.Gf//�..........O F......1��V9 .0 Srr4 f3L Appliratiou for Uiupuuttl Works owitrurtiurt Permit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: g p sal .............. -_....__.g...LOr r 1 /G�Zyl mac_' /-�-----p�...........--`-'•'�----...------• LocationtG7ss....60-....�N.G... ...... .. o Lot No %......... -•..... - - oz z L S Address a ..... �...:_.:.. ........................................................... �!YI.......---.._...L------•----..............-•••---•-•••........_. Installer •(1.-- Address Type of Building U Size Lot..... ,�.� ZS feet Dwelling—No. of Bedrooms...................5 __._.L..............Expansion Attic ( ) Garbage Grinder 4--)— Other—Type of Building ru' b_Z�No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .........--••••-••••-•--•-•-•-......_ d g ... ....................... W Design Flow............._.(.o.............. .. gallons per pes"n pgr day. Total daily tflow..................._.._........-. ....... lion . WSeptic Tank—Liquid capacity_. gallons Length&..(�.... Width:' (.0.._.'biameter:............... Depth c2...4:... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No........(........... Diameter.....�.�?........ Depth below inlet........ Total leaching area u .......sq. ft. Z Other Distribution box ( � Dosing tank ( ) / 1.' Percolation Test Results Z Performed b .. �- �P-A G-r...Azz��jffl�v !d v y .. Date _. 1.4 Test Pit i�lo. 1................minutes per mch Depth f Test Pit__.10-4 __.. ...... Depth to ground water...�Q .... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....----•........................................................................•--. O Description of Soil.. ....... ....5 . .......... W ------------------ .------------- .._..._....----------------------------- ----------------- •------- •---....... .....---- ................. -••-•----•••---------------••------•--•••---•------------------•----••-••-•-------------•-....----••---••-•-•-•----------•----a----•-.......---------••--••-------•--•---•-•........._........_......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...........................................•-•-•--------•--......--•-•---....----•-•--..........._......--••-•---•-----•-•---...---------....----......---•--......-• •-•--......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys em in accordance the provisions of A. L� 5 of the State Sanitary Code— "The undersigned furthe rees no o a e the syst n operation until a Certificate of Compliance has been issued by�theboard of health. a_L. Signed.............- " 1 Application Approved By...... .----•-•-•-• ... ....................................................... ' `................. . ..... Date Application Disapproved for the following reaso s:------••-•-•••...............................•--•-•••-...--•-•......---••----...............Date..•-•....._.. ...................................................•----•-.......---••----------.....---........................--...............-•---•--•-•----............'••..................--••--.....---•-........ Permit No...... ,f . ?.../ .. Issued..... f� 5'�1......nau...... Date Noll— ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH ..........7d'W. 1�.............OF..... Lam....... ....... .. ...... ... ............................................................................ Appliration for ilhipasal Works Tonstrurtion tit rafit Application is hereby made for a Permit to Construct (x) or Repair an Individual Sewage Disposal System at: LOT I T, i::)C,Giz > ....................... I. ..........---------------------------- --------------------------------------------------------- _7q V 15 Location-Address 6; or Lot No.Clio C --------------- .. ..... ...... ner 4) L Ad..dress .................................................................................................. ............W..'.. .................... ................................................. Installer Address Type of Building Size Lot.....4-:SIL:�LSq. feet Dwelling—No. of Bedrooms.................-*, ..../V.............Expansion Attic Garbage Grinder Other—Type of Building 4!MVP_./�P-A4 No. of persons............................ Showers Cafeteria W 04 Other fixtures .....................................C?LU............................................................................... .< C_�> _ ....*............Design Flow.............1.1 M ------ ....-gallons per person per day. Total d4ily flow............ ....gallons. Septic Tank—Liquid c*a"p"a"c'ity.A!VVgallons Length..�',� Width;.f f.f.0.... Diameter................ Depth2��_.A...... Disposal Trench—No. .................... Width_..._........_...... Total Length.........._......... Total leaching area....................sq. f t. Seepage Pit No......._(........_... Diameter.._..!v........ Depth below inlet........G:?....... Total leaching areal�71.......sq. f t. Z Other Distribution box ( K) Dosing tank ( ) Percolation Test ....Results Performed by.........!;.::....... ......J?eSO .aC`Q Date....... /�-1............ Test Pit No. 1....`_.Zin..mutes per inch Depth 4 Test Pit..J.-�&"..- Depth to ground Water. .140;j ...........rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._........_.._......._.. C41......................................................................................................................................... 0 Description of Soil.fki:... ..................................................................................................................................................................... -----­----------------- --------------------------*...........*.............**......*--------------------------------------­--------------*---*----------------­*-----------***---------I—- .................................................................................................................................................. ................................................... U Nature of Repairs or Alterations 7Answ& when applicable................................................................................................ I '�/ 7vd 1"7 ist'4 ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal S in accordalice with�� he provisions of TITLE 5 of the State Sanitary Code—The undersigned furth.e­,-a S Sys t undersigned o r:ees no to Ina,e the syste o'n f health. operation until a Certificate of Compliance has been issued by the board of health ;74M4 Signed................................................................................... .......... ............. Date Application Approved By.. glt� .... ..... Date ---------------------------------------*......... Application Disapproved for the following I S:............................................................................................................. ...................................................................................................................................................................................................... Date Permit No..... .g.....l.. Issued----- Date ---------------------I-- ---------------- ------------------------- THE COMMONWEALTH OF MASSACHUSETTS . BOA R1D1&O.F.. HEALTH ................Td. 0> ..........OF.... G .... ..................................... (9rdifiratr of Tompliana THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed V or Repaired b......... ..... ........ ...........�4-.( .................................................................................................................................................... x�l Installer f..... . ..... at....................................... A ........... Ista.................L��.............................................................. has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......6­ dated................................................ 4--------16R, - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... 9.. 1*1_11"1*­................. Inspector................ .................................................... I t_7 ---------------------_ ­....... ------------- ------­------------------ ...... ------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. OF......113qA�all� N ................. ......... ............................................................................... 711*'_PZ6 ................. FEE........................ Rapowd Norks TonstrWiatt VarAft Permission is hereby granted.......� .... ......................................................................................... V. to Construct (X-) or Repair an Indivio;ual,Sewage Disposa) System at No....&.Z ...... .........C�_ .?/...... .............. .. ........... ------------------------------------------------------- Street 1/) - 0. as shown on the ap ley—," ,plication for Disposal Works Construction Perini ANo.................... Dated_. j. --------------------------------- . .............. ------------------------------ DATE.... ................ Boanl Health .................. APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION Gt.T /� ' �!2c/::7r;-C__ ,���G c= o�r� NO.�7�= VILLAGE � }- I DATE Y.•27, fs APPLICAN'1_ FEE_ . ^ ADDRESS �(�q3 Z76 -Z- 9 TELEPHONE NO. 771-OB9�G (Non-refundable), ENGINEER .l�cs�u vc. „/�2. TELEP ON NO. 36z.-¢S�'f DATE SCHEDULED_ . (APPlicant-j--s's gnature) ..__:; . . . . . . . O O O 00 O . O . O O O O O . . O O • . • O O O • O O O • • • • . •O • • • O . • . . •. • . O O O O . ... . .'. O 9,0 O O . . ... ASSESSOR'S MAP LOT NO; SOIL LOG / SUB,-DIVISION NAMEFDl�� f �L LS DATE l /c°� �J TIME /O `CXJ EXPANSION AREA YES %�NO G. O nl(� c �nlG,gPE ENGINEER ,.. ..:. TOWN WATER�PRIVATE WELL J, Jcl[ AJLJC BOARD OF HEALTH `JJDeis o��•EXCAVATOR. SKETCH: , (Street name etc. 'dim'ensions 'ojf: t .lot .:ofte&a xholes and percolation tests, locate wetlands in proximity to test holes) NOTES: Ck A a\l v�. : Ilk PERCOLATION RATE- TEST HOLE NO: I ELEVATION: SD+ TEST HOLE NO: ELEVATION: •3 5 5 - 8 9 10 10 c'p`1H Of �q 12ALA 14 14 �gfc►sT ra 15 '15 E� , 16 6 ►opK E SUITABLE FOR SUB-SURFACE SEWAGE:' •. LEACHING•.FIELD LEACHING .PITS ` LEACHING TRENCHES .. UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ' ENGINEERING PLANS MUST SHOW NUMBER•ASSIGNED ON:PERC TEST APPLICATION. ORIGINAL: COMPLETED IN ENTIRETY BY P. F.AND RETURNED TO BOARD OF HEALTH COPY: `' RETAINED BY. APPLICANT ', _ 4 01 Asir,, 4T-I i I7ATU M ( 1.l(�1D I AkE1J ?_PM LISGS C( Tt.,'t T aLl A. Z.MUKA!UR&L WA'T�� Q�7(r.�• /[(' /FT Ul� ��i QTQi`S!S�. �i�YF.�. a.1.L.Pe6CAS'?" ` yr \ \ � 10 1 � Gr, GDr.1STKUG�!Oh: pETdttS 7b EniU!RON EnTbL. GODS TITI.� 1L i � 7�415 Vc,ba.l woP.K-o�L..y e�lD +..D tip?' �, ; ISSED Foe Q'zor`ceTy i sTbWt -, J f\ i) •..\ - {�_ 'TOP cG Foue-4vaTic+`� —2 ac �J l �' � \\ �� — -----�� --- � Sf • 7_ � t'M�i� i+ C�F���EQ. (�� ,p i �. 4 �. ._.s � � � +�a�T T� l� �G9':.�� (o`'mw�►� c�u`t' ©F c��A� ` Cp 4-Z ,Sv _ �. � ' -------/� Z' - �i4, �t�ZN 1r1GS�E���'or+•E Li V X lT c T 54 +Uu E( ? 4c ,, Co F .: a5� r Ate►{ FIT l�T l 1 ��`(ST4t. �''.'✓,�!~ lLp�iC7 � 11.4 I Z. of 1 c:,rlE A.t..t_ j I o E F F p!aNl xco,E FF Ve p s+4 down �� •mil,{. l� .f. 1, ' ' �IOcvr7 Go e Gn inUa'inc inG F 4-0 - �� i 4- t�i�� a Sc a S7a."I � civic ��✓ r��E� '��'�,�- �;", , �a ioc a�-Tr4 'may. MAI, 'R"TE �,d �(eeMoU7L1, N'.�� •w �---�-- i �yrn•°��-*"L�,,.�. �, 1 R.L,�. •ram '.