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HomeMy WebLinkAbout4463 FALMOUTH ROAD/RTE 28 - Health 4463 FALMOUTH RIDA'P COTUIT -- - - --- A = 024 031 LOT 5 U TOWN OF BARNSTABLE LOCATION TTO3 u o SEWAGE # j -VILLAGE C_GTf.:r( � n INSTALLER'S NAME&PHONE NO. .L`W/-/ /19'071E SEPTIC TANK CAPACITY 1500 .LEACHING FACILITY: (type)Z-;_'00L6A4# 469/42/45 (size) /34Z5)(a,' NO.OF BEDROOMS 3 BUILDER OR OWNER G PERMITDATE: ZQ-Q�A-QQ COMPLIANCE DATE: 111VL(M Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet J g Y , Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) } Feet Furnished by K E L G ac __ , . �-Sao ��t�-o►�(�EAG��Cl-hS r No�C r . .,. `s Fee 1l®.// THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes pPUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS Application for Mtgogal pztem Cow6truction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. dl- Assessor's Ma /Parcel - �� p / L S U ve Installer's Name,Address,and Tel.No. ��f/W gwro Designer's Name,Address and Tel.No. T 0,v 7A60W CIA a 0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 72 C� ~ Lw�/�i "'s- Sg• re a=mil R�g d d ?3 a� Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. && Description of Soil Nature of Repairs or Alterations(Answer when applicable, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E o me Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by 's Board f all . Signed Date Application Approved by Date ley Application Disapproved for the following reasons Permit No. ZdVV Date Issued Zee 6 0 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes V P PUBLIC,HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Rpprication for �Diopooar 6potem Conotruction Vertu Application for a Permit to Construct( )Repair(v)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -� Owner's Name,Address and Tel.No. Assessor's Map/Parcel , ��� - 0�203� � 3" LL s� � U10E��7 QR,039(IL Installer's Name,Address,and Tel.No. �R�/ 7G Designer's Name,Address and Tel.No. 40 7W7VF ae. MAP! �ors #7/US 9.20-�. -VF Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Bu ldinLy No.of Persons Showers( ) Cafeteria ) \ Other Fixtures �� - U w o/c /S?I S9• ►'2. wit q S-c�y�d Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank G� Type of S.A.S. - +? - Description of,$oill, Nature of Repairs or Alterations(Answer when applicable /Ua f 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 ptovttstons of Title 5 of the E Vb me Code and not to place the Os'i&im-i r operation until a Certifi- cate of Compliance has been issued by s Boar of Signed Date Appli ac ti'onApproved by Date Application Disapproved for the following reasons Permit No. y Date Issued ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERM�he�n�ite, age Disposal System Constructed( )Repaired(�)Upgraded( ) Abandoned, ��� at JJ Gv has been constructed in accordance with the provi Title and the for Disposal System Construction Permit No. _ G � dated ' 1� °2�'�d Installer %��� � ��» Designer /A A• ©< The issuance of this pe s dal o ,c s ed as a g uarantee that the s,' tem •iI1 unction as des ne/ " Date l�/ Inspector --------------------------------------- No. Fee p Z q-b THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopooaf bpsstem Construction Vermit Permission is hereby gra}}tn�st u ���j�pai %U��ad�(� )_Abandon( ) System located at `f-�L f !'t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed with* three years of the date of this e�it. Date: /L% " Approved by `C �'�' �� 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the:aJppl catiori for disposal works construction permit signed b dated p y me , concerning the property located at VC)TY Ap, meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business ( uses associated with the dwelling. 1 The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. 1 There are no wetlands.within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system l There is no increase in flow and/or change in use proposed There are no variances requested or needed. �. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 7o B) G.W.Elevation +the MAX.High G.W. Adjustment. _ _JJ DIFFERENCE BETWEEN A and B SIGNED : DATE: [Sketch proposed plan of system back]. q:health folder.cart f t f �iS f Property Location:,4463 R'OUTE18,SANTUIT MAP ID: 024/031/// Vision ID: 1321 Other ID: Bldg#: 1 Card 1 of 2 Print Date:11/09/2000 eve^ L ublic a er Description Code Appraised value Assessed value O BOX 1800 as ave EXEMPT 9060 117,500 117,500 801 ASHPEE,MA 02649 ep zC EXEMPT 9060 6,500 6,500 Barnstable 2000,MA %PARISH OF CHRIST THE KINGTA ccountPlan Ret. Tax Dist. 200 Land er.Prop. #sR Ct# VISION Life Estate DL 1 LOT 5 Notes: DL2 GIS ID: 1watIll , a, 4 .. .. _ s r. o e Assessed value Yr. I Code Assessed value Yr. Code Assessed value T9"9060 > > > 60 1999 9060 94,5001998 1010 92,700 1999 9060 3,1001998 1010 3,100 ota: 137,70 Total: 135,900 Total: "�: : 'ram , : "' = zw �. �..w. •_ : ., , . ' zs signature ac now ges a visit y a ata o ector or ssessor st n e ear lypelvescription Amount Code Description Number Amount Comm.Int. r . V ULr• Appraised Bldg.Value(Card) 71,400 Appraised XF(B)Value(Bldg) 0 Appraised OB(L)Value(Bldg) 6,500 ota Special Land Value raised Land Value(Bldg) 40,000 I HE MIN G THRIFT SHOP Total Appraised Card Value 117,900 Total Appraised Parcel Value 164,100 Valuation Method: Cost/Market Valuation et TotalAppraised Parcel Value 164,100 \ f i, p, --Permit ID Issue Date lype Description Amount Insp. ate o omp. ate Comp. omments Date ID Cd. Purposelmesult ea orrec a es mg a ,. .: � .a v ... •� .::...�.... ,. ... �. :_. �, � .aIkAiL:�,s �;� � ,a.�r:. ;ate+•• Use code Description Zone D Jrontage Depth Units Unit rice actor actor Nbhd. /. Notes-AdjlSpecial Pricing A aj. unit Price Lana value T—WO—CHURCH ETC RIF LOU AU . ., o es:1U IBLIM 40,0U0.00 40,00 Totat Cardan nits FW A-C---Pa-rcel I otal Landrea: Total an a ue 40,00U Property Location: 4463 ROUTE 28,SANTUIT MAP ID: 024/031/// Vision ID:1321 Other ID: Bldg#. 1 Card 1 of 2 Print Date: 11/09/2000 � , s s.: ;., v- ., �� :, tea. .. ,, ;�... � : .._ .: � � ..� -; " . , ,. .; AU Element Cd. Ch. Description CommerciaDa ta ements Style/Type 4 Cape Uod Element De.crzptzon Model 1 Residential Heat AU- Grade C C Frame Type Stories .5 1 1/2 Stories Baths/Plumbing 24 Occupancy 0 CeilingfWall ooms/Prtns Exterior Wall 1 14 ood Shingle /°Common Wall 2 Wall Height BAS Roof Structure 03 able/Hip Roof Cover 03 sph/F GIs/Cmp . h t1A Interior Wall 1 03 Plastered Element o e Description actor 2 4 2 Interior Floor 1 14 Carpet Complex FHS 2 Floor Adj Unit Location BAS 1 Heating Fuel D2 Oil 17 BMT Heating Type D4 Hot Air Number of Units C Type 3 entral Number of Levels /o Ownership Bedrooms 00 Zero Bedrooms Bathrooms 1 1 Bathroom $: 10 1 Full - , .;, 6 13 na 1.Base to Total Rooms ize Adj.Factor .07277 Grade(Q)Index .98 ath Type Adj.Base Rate 0.46 Kitchen Style Bldg.Value New 5,984 Year Built 1970 24 ff.Year Built A)1980 rm1 Physcl Dep 7 uncnl Obslnc on Obslnc h pecl.Condo Code pecl Cond /o Code Descrz lion Percentage Overall%Cond. 83 eprec.Bldg Value 71,400 y s , <� o e Description LIB Units Unit Price Yr. Dp Rt uloCnd Apr. Value Garage- vg wbull o e Description LivingArea Ciross Area .Area unit Gost Un eprec. Value —IFAS—kirst Floor 1,056 1,056 , BMT Basement Area 0 720 144 10.09 7,266 FHS Half Story,Finished 504 720 504 35.32 25,432 IM Gro!Liyll ease Area g a: 859984 "Property-Lockdoh:-4463 ROUTE 28,SANTUIT 024/031/-//" Vision ID: 1321 Other ID: Bldg#: 2 Card 2 of 2 Print Date:11/09/2000 ROMAN UA I kJ[ULJLU HISHOF Ot k K u is watei Description code jAppraisea value Assessed Value %PARISH OF CHRIST THE KING as I ave EXM LAND V060 40,100 —4UJOU PO BOX 1800 6 eptic I EXEMPT 9060 117,500 117,500 801 MASHPEE,MA 02649 7��� EXEMPT 9060 6,500 6,500 Barnstable 2000,MA AW"T=M, ccoun11402 Flan Ret. ax Dist. 200 Land Ct# Per.Prop. #SR Life Estate #DL I LOT 5 Notes: VISION #DL 2 CIS ID: Total 64,1001 164,100 "NAL&F-WICL, NEE,M�1459M, 011113-11 ROTWON%-A I HUL14-111SIlor Of I,K LMul i4b U wu D rr. code Assessed Value Yr. GO e Assessed Value Yr. Code Assessed value T9993UW-------—--49,TUU1998 101t; 146,600 19999060 94,5001998 1010 929700 19999060 3,1001998 1010 3,100 —To-t-aT- 137,70U,—Total: —05y"WN—-To--IaT- 146,60U S-7-- This signature 3 T ack4owledges a visit py avata Collector or Assess—or A 9, fi'A, ��, �s, U rear ypelDescription Amount code Description Number Amount comm.Int. LV Appraised Bldg.Value(Card) 46,100 Appraised XF(B)Value(Bldg) 0 Appraised OB(L)Value(Bldg) 0-- Totald Appraised Land Value(Bldg) 100 Special Land Value Total Appraised Card Value 469200 Total Appraised Parcel Value 164,100 Valuation Method: Cost/Market Valuation al Appraised Parcel Value 1649100 fqlyr 1,4-1 a 'I "141"A A A, Permit ssue Date lype Description Amount Insp.-Dale- "lo Comp. Date Comp. omments Date ID ca. Purposellcesult --77Y2799-- FS 07 Mea+Corrected ListFn-g- -1 'UIX I" H4 Use Code Description one V lProntagel Depth Units Unit Price L Eactor S.I. U.Pactor Nbh al. JV0,eS-AdjISpeciat Pricing Adj. Unit Price an value L WOO UBUKUH ETU RF 2 0.01 SF 62. otes: ---------qUW. IOU Total Card an Unitsi O.00IAC Parcel Tota anArea:j F.UO-A-C 1 oral an Value Property Location: 4463 ROUTE 28,SANTUIT MAP ID: 024/031/// Vision ID:1321 Other ID: Bldg#: 2 Card 2 of 2 Print Date: 11/09/2000 w. a Element Cd. Descriphon ommerciaivata Elements Style/Type H RanchElement Cd. Gh. Description Model 1 Residential Heat Grade C C Frame Type WDK Baths/Plumbing Stories Story ccupancy 0Ceiling/Wall ooms/Prtns 1 Exterior Wall 1 14 ood Shingle %Common Wall 2 Wall Height Roof Structure 03 able/Hip Roof Cover 03 sph/F GIs/Cmp 14 Interior Wall 1 8 Typical V' ° r 2 Element Code Description Factor UBM Interior Floor 1 12 ardwood omp ex 2 Floor Adj Unit Location Heating Fuel 7 Mixed Heating Type 4 Hot Air Number of Units C Type 1 None Number of Levels /o Ownership 2 Bedrooms 02 2 Bedrooms Bathrooms 1 1 Bathroom : , may% — 'I 0 1 Full Unadj. BBase Rate 48.00 Total Rooms 4 4 Rooms Size Adj.Factor 1.31122 Bath TypeGrade(Q)Index .97 YP Adj.Base Rate 61.05 Kitchen Style Bldg.Value New 59,829 Year Built 1955 132 ff.Year Built A)1974 rml Physcl Dep 3 uncnl Obslnc con Obslnc Spec].Cond.Code pecl Cond% Code Desc7tion Percentage Overall%Cond. 77 eprec.Bldg Value 46,100 Code Description LIff Units Unit Price Yr. Dp Rt %C;nd Apr. Value r W � � . A, !"Al"Fes.. _ �: �" � n q r%�. .. ,. %• Code Description LivingArea GrossArea Eff.Area Unit Cost Undeprec. Value First Floor UBM Basement,Unfinished 0 800 160 12.21 9,768 WDK Wood Deck 0 196 20 6.23 1,221 IX Gro!Livliease Area g Val: , TOWN OF BARNSTABLE i LOCATION T-1 3 -aav,-k R0, SEWAGE # 00 VILLAGE feu, ( ASSESSOR'S MAP & LOT j INSTALLER'S NAME&PHONE NO. eW/V i9yoTrE SEPTIC TANK CAPACITY IS�� LEACHING FACILITY: (type)�2-500 L64(# 60 5 (size) /3 X 95A a.' NO. OF BEDROOMS BUILDER OR OWNER PE.RMITDATE: COMPLIANCE DATE: Separation Distance Between the: j Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet .Edge of Wetland and Leaching Facility(If any wetlands exist Feet ,within 300 feet of_leaching,facility) Furnished by i • i. y ' A 1 1 , 005/ � I _ is lot AAL Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of w c;14, • Environmental Protection, c William F.Weld /. Governor Trudy Cox@ Secretary,EOEA y David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A / CERTIFICATION4 Property Address: '��� 3 /" �( [ ® V�� f Address of Owner: l� Date of Inspection: �v� c— ¢C, (If different) Name of Inspector: � ,(f� S Company Name, Address VA ephone Num(�jber: 6 1 4s f -- a0 3 CERTIFICATION T TA EMENT 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 t f inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site disposal systems. The system: _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: m Ins ector shall submit a copy of this Inspection report to the Approving 14— AuthgGrtY within thirty 130) days of completing this submit The Syste p 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 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) SYST PASSES: 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. e) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes Inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. if"not determined", explain why not) _ The septic tank Is metal, cracked, structurally unsound, shows substantial infiltration or exfiltratlon, or tank 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. �r revised 6/15/95- 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 %J Pnnted on Recvcled Pater t f V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ��gar s t � fr e vfV V-r-_L Owner: Y ill rid Date-,i Inspection: 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): broken pipe(s) are replaced 1 obstruction is removed distribution box is levelled:or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _. _ The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: a I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded-or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. revised 8/15/551 2 I .f I; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART A CERTIFICATION (continued) Property Address: r5 � � e i Owner: i I Date of Inspection: D) SYSTEM FAILS (continuetf):� 1 — 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 1/2 day flow. t _ Required pumping more than 4 times in the last year NOT due-to clogged or obstructed pipelsl. ;€ i 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 a surface water supply or tributary to a surface water. supply. — i Any portion of a cesspool or privy is within a Zone I of a public well. f i _ 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 of well water analysis withf no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the syem se consult the localnreg regity into ional office f ofl compliance the Departmenttforhfurtherrinfoamationatment program requirements of 314 CMR 5.00 and 6.00. Please 3 (revised 8/15/951 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B i CHECKLIST Property Address: Owner- Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. 6�4one 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 pan of this inspection. if tVs built plans have been obtained and examined. Note if they are not available with N/A. he facility or dwelling was inspected for signs of sewage back-up. e system does not receive non-sanitary or industrial waste flow e site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, rial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. T'he size and .ovation of the Soil Absorption System on the site has been determined based on existing information or Zpro�fa'otv, d by non-intrusive methods. _ i owner land occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. ,revised 8i15i951 4 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �l�' Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents:_ Garbage grinder (yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available: Last date of occupancy: 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: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: i TYPE OF SYSTEM F Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool c Privy s Shared system (yes or no) (if yes, attach previous inspection records, i.fany) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) ,revised 8/:5/95! 5 c C 1 A. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �/y I ' 1 0O Owner: Date of Inspection: t� SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural (recommendation for pumping, integrity, evidence of leakage, etc.) GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _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: Comments: , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural (recommendation for pumping integrity, evidence of leakage, etc.) 6 ;revised 8/15/95; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION /(continued) Property Address: ' / f./ y A- tY � Owner: _ Date of Inspection: 4 v ,�� � C.�/ /' Sly TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: ' Material of construction: ,_concrete _metal _FRP —other(explain) Dimensions: Capacity: Qallons Design flow: QalIons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (notalondition of pump chamber, condition of pumps and appurtenances, etc.): (revised 8/15/95) 7 I a t� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM ?SAS):- (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:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: 'Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatton,etc.) CESSPOOLS: _ (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.) 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.) revised 8/15/95) 8 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) r Property Address: ;'L� G �j�1 o v Owner. 01/1LL,ST Date of Inspection: !/ SKETCH OF SEWAGE DISPOSALS TEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i C� a 7T- C4 O . � L � �rss�aol DEPTH TO GROUNDWATER Depth to groundwatefeet -� method of determination or approximation: ( / / /( S 140 ae­C et .revised 8/15/95) hall— USA _ t ( eLL E U-s fo is��»g 9:4 Ire -- -+-, 1. w t�.d o v✓I , r; -L 801? PLA /V New Roo r, u$'� Y, • I ' � � Low oISIS • .. .� � • _New Doo-c • � 'l►fie f - ' tic �Xls rH New I37CtLCw4 oor oGa �fy N� 4 c nleW off FLoar Y�-rc�" w.eti. q — q p ' { ivz �e S �e FoL v l APPROVED BY -.. SCALE: DRAWN BY `J-1T M DATE: Z G REVISED t oll[.I 00 - - �l tl �. T1b 4 DRAWING NUMBER