HomeMy WebLinkAbout0072 LAKE STREET - Health , ,� c Street, C otxtit
��
ASSESSORS MAP NO: ®�
PARCEL NO: Od
No..............
�'
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
----------------T.own ......OF.........1��rust.�ble
Appliratiun for UiipuuFal Works Tom trurtlun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
....7.2... ...Cot-uit-----------•----------------------- --.-----------------------------------•------
Location-Address or Lot No.
EQX.111................................................ .................................................................................................
Owner Address
-Pa CQJ 2Q.X............................................................
Installer Address
dType of Building Size Lot_-_---•-•-•--_-----------•Sq. feet
V Dwellings No. of Bedrooms......... ._...Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons.............______-__-____ Showers ( ) Cafeteria'( )
a Other fixtures -------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow..............................._............gallons.
« 9 Septic Tank—Liquid"capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................
.-
444 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -•--•----•------------------•--•-•-----•••-•-•-•--••--••-----•-....••-••-•--••-•-------••----•••.............................................................
ODescription of Soil...OAIIa..........................................................................................................................................................
x
W
U Nature of Repairs or Alterations—Answer when _____________________
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L i j s:a+. y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance hahei.s ed by the turd of health. /Signed .. ••. ......---- •6 �87--------•-
Date
Application Approved BY --•----•---��
Date
Application Disapproved for the f ollo * reasons:-----•--------------•--.........----•-------------------------------------------• .....................
----•-••-----•••-•••---•••---•••-•-•----...•••--...-•-•-••-•--......•••-•--••----....••••-••-•-•...........•---•-----------•••-•••-••------•-----•-•---------•-••--•••---••------------------•-•--------.
n Date
PermitNo...... _� .. •----•---••--••---..... Issued-------------------------------------•---•-••-•--------
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
Im A
DATA
Nd o _`TZ3 Fizz. .......:.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Dhipaiial lVarkii Tonstrurtion ami#
Application is hereby made for a Permit to Construct ( ) or Repair (. ) an Individual Sewage Disposal
System at:
l .........._=�•--=t-r c-.t......: -t.-a : .............................•........ -•--•-•-----------------•---•-----•-------- ----------------------._........---------
Location-Address or Lot No.
r t Ct -_..Y_1.C---.._.....-•------------------------------•---.... --•-------•------._.....-••-----....................----•........_---_..._.._.....-••.._-..__..._
-t
Owner Address
r.r.... ....... •••------------•----------------------- ...
Installer Address
Type of Building SizeLot____________________________Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of ersons____________________________ Showers
Pa YP g --------•------------------• P ( ) — Cafeteria ( )
Pa Other fixtures ...•--•-•--------------•------•- -
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area____________________sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
►-' Percolation Test Results Performed by........----------•----------•------------------------------------------• Date........................................
Test Pit No. 1__..............minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ••-----•--•-----------------•-------••-•----•-••---------.....-•--------._..........---...----•..__.._.......-----••---••-•---•------•----.......-----•------
DDescription of Soil.-"- r'-d-----------------------------------------------------------•-•----•-------------------------------•------------------------------------•-------------------
x
U ••••••---.....................................................................................................................................................------------------------------
w
UNature of Repairs or Alterations—Answer when applicable.__. -1: = 1_____ ' 1 C t, �.i ..
--------------------------------•--...---------------------•------•••-••-••••---------------------•-•-•---•-----•-••••--••-•-•--•••---•---•----••••-•-•--••-•---•--•---•-•----------•••-------------•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T".4: j 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 board of health.
+� Signed =--------- .....:......................................r _ ......
Date
Application Approved BY .._..r�! V .-�`'" --•------ J.....................•-----------------------
Date
Application Disapproved for the f oll ing reasons:----•----------------------•----------------•---•--- ........................................................
---•--•-•-----••-••----•------•-•....-•..............•----------...--•-••-•-••••-----........•---------------------------------------•--------••---••-•------•--•--•--•--••-••••----•--................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ...................OF.............L 1 r €t tit 1F
fit
wrtif iratr ,af Tompfiattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired � }
bY--•-----�._r..---.....-•••---•---•--•---------------•-----•----------•--------------•-••-------•••----.....------•--------------------.._._...---------..._-------••-------------...---...----
Installer
at--------7 r j_q_s e L t r e c t ."0 t .�!t
has been installed in accordance with the provisions of - at the State Sanitary�de as>>descriD-- m the
application for Disposal Works Construction Permit 'o. __,____________________................ dated--.. __'_._7�-'_��_________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... '-a ........................... Inspector....._. ... ...---.....----------
THE COMMONWEALTH OF MASSACHUSETTS
Z / BOARD OF HEALTH
No... __ FEE.`.....................
%posal Works T41ustrt Uatt "remit
Permission is hereby granted__.G►_t_ '!_ '� l� . ......__._
to Construct (}}- )[[aor ftagir t )r.,at1 Ittdjvidual Sewage Disposal System
T J S� e 4? A ae y 6� is k_ice.
Street J ���
as shown on the application for Disposal Works Constructio r it No�___ _____ _____ D.Ited___ _ ._ _V........... .__.
.-•-•- Ur -------- .: -��_.s ..�--•--••........................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ,
TOWN OF BARNSTABLE
LOCATION �„, � 2 SEWAGE # Vj'-IZ3
VILLAGE ASSESSOR'S MAP & LOT 36 .9
INSTALLER'S NAME & PHONE NO.�/
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ��
/ (size) !'L
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WAS' -
BUILDER OR 2WNER_��%
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
V
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*72-
A
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, a ate R
\• COMMONWEALTH OF MASSACHUSETTS
ENVIRONMENTAL FF � c � E
EXECUTIVE OFFICE OF E?.-VIRO A c�- 2 3 )RUDY
DEPARTMENT OF ENVIRONN ENTAL PRO TIO?i�yN, 1ONEWINTER STREET. BOSTON. htA 0]106 Fi'-=S_•':'0( �lTHp�TAe�F9%VILLIAV F WELD a
Govcmc-
ARGEO PAUL CELLL'CCI DAVID B STRI E
Lt.Govcmor SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM . Commission.
PART A
CERTIFICATION
Property Address: 1P,)- <,glC,t. \ , &"N. Address of Owner: C he1J
Date of Inspection:_ 1 6 fa etl Of different) •'1-LLAX_A_
Name of Inspector, I Cdeo
am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: ) a yr�c'a _En Y r'I'r�.1 wt P•A 4---/
Mailing Address: -4>Q /3 opt �_3� H f�S N�2t2 H -*I-C:l 2S'4-q
Telephone Number: r5e4) _C� �,'�- /Lrc Z=
CERTIFICATION STATEME%%T
I term that I have personalh inspected the selvage disposal system at this address and tha. the information reported be!ov, is true. accurate
and cornolem as of the tame of inspec:oo-. The inspection was performed based on my training and experience in the proper func,or. and
maintenance of on-scarce se%age disposa- systems The system:
x Pastes
Conc,t-onaii% Passes
'Seeds Furtne- Eva!uaron B� the Local Approving Autnonn
Fa.-.
&w Inspector's Signature: Date: �0
The Svse^ Inspecto- sha" submit a cop% of this inspection report to the Approving Authorm within them• (30, days of completing this
inspector.. It the sister: is a shared system o• has a design flow of 10,000 god or greate•, the inspecor and the system owner shall submit
the repo-t to the aporoor,ate regtor.a) office of the Department o; Environmental Protet:.e The ongma! should be sent to the system owne-
and copies sent to the buver, if applicable. and the approving authorim
INSPECTIO% SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
4— 1 have riot 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: l w
S c,ic-
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass- sec-ion need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by 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 ihe'system inspector with a copy of a Certificate of
Compliance tattachedt indicating that the tank was installed within twenty (20) years prior to the date of the inspection; o
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will-pass inspection if the existing septic tank is replaced with a conforming septic tank
w approved by the Board of Health.
lr•.:a•d 0�/IS!!') Page 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES lcontini-d
_ Sewage backup or breakout or high static water level observed in the drstrib box is due to broken or obstructed
prpe: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 levelled or replaced
_ The system required pumping more than four times a year due to bro n or obstructed pipe(s). The system will pass
rnsoectron if twith approval of the Board of Health):
broken pipets; are replaced
omtruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of H Ith in order to desvmine if the system is failing to protect the
public health, saie*,,•and the environment.
1) SYSTEM WILL PASS L!%LE55 BOARD OF HEALTH DETERMINE THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY ND THE ENVIRONME%T:
Cesspool or pri%ti is within 50 fee: of a surface wat r
Cesspool o: prn) is w ithin 50 feet of a bordering egetated wetland or a $ah marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH ND PUBLIC WATER SUPPUM IF APPROPRIATE) DETERMINES THA;
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT ROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The s\•stem has a septic tank and soil abso tron system (S4St 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 sort a orptron system and the SAS is within a Zone I of a public water supnry well.
The system has a septic tank and soil sorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil bsorptron system and the SAS is less tf:ar: 100 feet but 50 feet or more from a
private water supply well, unless a elI water analysis for coliform bacteria and volatile organic compounds indicates tha
the well is free from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to etermine distance (approximation not valid).
3) OTHER
Pray 2 of 10
or
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO'1 FORM
PART A
CERTIFICATION (continued)
Propery Address:
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate either `Yes` or *'No' as to each of the follo\,%•tng
I have determined that the system violates one or more of the following failure criteria as defrned 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.
Yes No
Backvp of se%age into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pond,ing of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or
cesspool.
Sta:ic hc6;,d level in the distribution box above outlet invert due to overloaded or clogged SAS or cesspoo!
Lieuid death it cesspool is less than 6" below invert or available plume is less than 112 day floe.
Reowred pumping more tha-- 4 times in the last year NOT du to clogged or obstruaea pipe s
bumper o;times pumped _.
Any port;on o'the So:! Absorption Svste-n, cesspool or pr - is balow the high groundwater eievatto-,
An% por:or o;a cesspool or privy is A ahin 100 feet o a surface water suppiv or tributan to a surface %ate• supple,
And po^tor, o;a cesspoo' or priv- is within a Zone of a public well.
An\, pe e;a cesspoo' o- pr;v-; is within 50 f t of a private water supph wel!
Am po^.o- o:a cesspool or prt%-�' is less than 00 feet but greater than 50 fee: from a private water supoiv well with no
acceptable %ate• qualm ana)vs s If the well as been analyzed to be acceptable. arach cope of well water analysis for
colnorm batter+a vo!a-.de organic co^poun s, ammonia nitrogen and nitrate nitrogen,.
E] LARGE SYSTEM FAILS:
ltou must indicate eithe, "Yes' or "No" as to each of the f Mowing.
The ioho%,m,g crite•,a app;% to large systerns to ddition to the criteria above:
The system serves a facllin with a design fio of 10,000 gpd or greater (Large System; and the s\,stem is a significant threat to
public health and safes and the enviror,me t because one or more of the following conditions exist:
Yes No
the system, is within 400 feet f a surface drinking water supply
_ the system is within 200 f t of a tributary to a surface drinking water supply
the system is located in nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
public water supply we )
The owner or operator of and such syste shall bring the system and facility into full.compliance with the groundwater treatment program
requirements of 314 CmR 5.00 and 6.0 PI consult h ea_e ce su t the local regional office of the Department information.
for further ini rm ' n
eg pa o .
(rwsaad 04/25/si) Page 3 of 10
. r v
SUSSLIRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert% Address: 11,
Owner: Cjv`
Date of Inspection: 1 U `%Lk qq
Check if the following have been done: You must indicate either "Yes"or "No"as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
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 recentl% or
as pan of this inspection
As bull' plans have been oo:a:ned and evarnfined. Note if they are not available with N/A
_ The fac!IM or d%+elhng %%as inspected fo, signs o�sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site %+as inspected for signs of breakout
Ah systerr components. excluding the So-: Aosorption System, have been located on the site.
•, _ The septic tank rnanhoies were uncovered. opened. and the interior of the septic tank was mspecied for condition of
baffies or tees. materia. o'cons:ruc-,ion. dimensions, deptn of liquid,depth of sludge, depth of scum.
—'The size and locat-on o.'the Sol' °.bsorp;oon Systern on the site has been determined based on
The fac.l,t,, o\%ne• ,ano occupants. jf d;fteren: from owneri were provided with information on the prope, maintenance of
Sub-Surface Disposal System.
_ a Existing information Ex. Plan a: B O H
_ Determined in the field of an,. of the failure criteria related to Part C is at issue, approximation of distance is
unaccea:ab e (15.302.3;:b
(revised 04/25/57, Yrg• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properh Address: 1r 2 Lro�
Owner: t0
Date of Inspectioh:
�1
FLOW CONDITIONS
RESIDENTIAL:
Design flow .p.d..rbedroorr, for S.A.S
Number of bearooms Oz:)
Number o-.current resident#(Vnor
Garbage g•, der (yes or no
Laundry cc-•^ected to syste no' k4loz
Seasonal use Ives or no-.�1C�
Water meter readings. if available (last two f2 year usage tgpd). (, C(b
Sump Pump Ives or not e
Las dare o"occupanc\ W��A- SflaT"
COMMERCIAL'INDLISTRIAL•
Type of establishmen:
Design fio%% ¢ahonsrda%
Grease trap present rues or no_
Industria! 1%aste Holding Tani; vresen; -ves or no_
Non-sanita-� waste d,scnargec to the T,,e 3 sys;ern Ives or no
%%ater meter readings if a•:a,labie
Las:Fa:e o: o c_;a-:e.
OTHER: .Describe
Last sate of occuoanc.
GENERAL INFORMATION
PUMPING RECORDS and source of mformanor
&A-1101 W k 0 QWNsAY
System pumped as par, of inspection: tves or no. t�
If yes, vo:ume pumped '6S(30 ¢allons
Reason for pumpinEAtNt1�t1 a
TYPE OF SYSTEM
Septic tanVdistri ution boxrsoil absorption system
— _ Sing a cesspool �6 (1te•CNNsr.�� t \
Overflow cesspool
Pr").
Shared system (yes or no' (if yes, attach previous inspection records, if any)
VA Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: _S(NC\P S QV,tYa� �t7�J C1tJ�1��Co 1S
t -i isyz �N ,e C\\
Sewage odors detected when arriving at the site. (,yes or no) L
(revised 04/25/91) Page 5 of 10
SLBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
.BUILDING SEWER:
(Locate on site plan)
Depth below grade.
Material of construction. _cast iron _40 PVC _other (explain,
Distance from private water supply well or suction It-,
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan
Depth below grade
material of construction _concrete _meta _Fiberglass _Polvethvle a _othertexplain
If tank is meta. Its: age _ I; age cor..'amec b� Ce^:fica:e of Compu ce Des.-No
Dimensions
Sludge depth
Disiance from top o: swage to bonorn of ou:;e: tee o• ba-;e
Scum thickness
Distance from top of scum to top o� outle: tee or bade
Distance from bosom o; scu—• to bo-o'-. o;outlet tee e• ba*.e
How, dimensions mere dete•minec
Comments
trecommendation for pumping condition o; inie: and outl tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage. etc
GREASE TRAP:
(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 or baffle.
Distance from bottom of scum to bottom f outlet tee or baffie
Date of last pumping:
Comments:
(recommendation for pumping, con tion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage. etc ,
(revzoad 04125:37) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.'-1
PART C
SYSTEM INFORMATION (continued)
Propert% Address:
OM ner:
Date of Inspection:
TIGHT OR HOLDING TANK: '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(expla* )
Dimensions.
Capacm- gallons
Desig^ floN gal:ors'da.
Alarm level A:a,m ir. %%orking order_ Yes. _ No
Date c; previous pumping
Comments
(condition of inlet tee. cond000r o' a'a•m. and float switches. etc.)
DISTRIBUTION BOX:_
Jocz:e on site p a-
De,-:: c; Iiou!d le%e' aoo.e outne: m,e-:
Coin-e-u
incite le�•e' and d:srjb.:-or. is eaua' ev,dence of solids .rvover, evidence of leakage into or out of box, etc.l
PUMP CHAMBER:
(locate on site plan_
Pumps in working order: (Yes or No'
Alarms in working order (l es or No
Comments.
(note condition of pump chamber, condition f pumps and appurtenances, etc.)
(revised 04/25/971 Page 7 of 10
t. i.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properh Address: 7� Lvt�
Owner:SKOq
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site,plan, if possible, excaTon 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 fieids, numbe•, di-nens;ons
over;low cesspool, number
Alternative wslem
Name of Tecmr.oiog,.
Comments.
mote condA ion of soli, signs of hydraulic failure, leve`: of pondin cgndit n vegetation, etc.t c
`
1jL
CESSPOOLS:
(locate on site p ar
Numbe, and con;jg;;ra:,on
Deoth-cop of liquid to inlet in.,en <<
Depth of solids lave-
Depth of scum layer ?�
Dimensions of cesspool S x l a
Materials of construction &LjC_*Jc'r
Indication of groundwate• N0
inflow (cesspool must oe pumpea as par, of inspection: Vy. VV\Rt+JTrt ( ,
Comments:
In Ate ndition of soil, signs of hydraulic failure, level of ponding�con iti of vegetation, etc.)
�j elco
PRIVY:
(locate on site plan)
Materials of construction: Dimensions.
Depth of solids:
Comments:
(note condition of soil, sigrs of hydraulic failure, level of pondmg, condition of vegetation, etc.,
travaaad 04/25/9?) Page a of 10
' h
.I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORA
PART C
SYSTEM I%FORMATION (continued)
Propert% Address: 72 L—$k .(;,
Owner: S► O
Date of Inspection:
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)
rQoa i
A �
3
—A%-`>�
k'L-10' S2 S�`
U@.vial 04'25/9"i Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM I►VSPECTIO% FORM
PART C
SYSTEM INFORMATION (continued)
Properri Adj_dAress: 7
Owner: S►W
Date of Inspection: ,V+(11 k
Depth to Groundwater''( Fee:
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation of Site (Abutting propery, bsenat,on hole)basement sump etc.)
Determine it from local conditions
Cneck %%ith Iota' Beard o' .'1e2::r
Check FEMA Maos
Check p;tmping records
Check. Iotal excavato- jrs:a'le•s
Lse LSCS 'Da:a
r,
Desc'nbe in voi, o%%- \%o•c- no-., %o- esa--;:s=ec the Cround%ater Elevation. (Must be completed
(zwaied 24.2519'. Page to of to